
Book ^3 7 

CopigM? 



COPYRIGHT i>EPOSE£ 



Nervous Exhaustion. 



HORSFORD'S ACID PHOSPHATE. 



Recommended as a restorative in all cases where the 
nervous system has been reduced below the normal standard, 
by overwork, as found in brain-workers, professional men, 
teachers, students, etc., in debility from seminal losses, dys- 
pepsia of nervous origin, insomnia where the nervous system 
suffers. 

It is readily assimilated and promotes digestion. 

Dr. Edwin F. Vose, Portland, Me., says: "I have pre- 
scribed it for many of the various forms of nervous debility, 
and it has never failed to do good." 



Send for descriptive circular. Physicians who wish to test it will be 
furnished, upon application, with a sample by mail, or a full-size bottle 
without expense except express charges. 

Prepared under the direction of Prof. E. N. Horsford, by the 

RUMFORD CHEMICAL WORKS, Providence, R. I. 



Beware of Substitutes and Imitations. 






MPOTENGE 



SEXUAL WEAKNESS 



MALE AND FEMALE. 



y^ 



/ 



EDWARD MARTIN, A.M., M. D„ 

Surgeon to the Howard Hospital: Clinical Professor of Qenito-Urinary 
Surgery, University of Pennsylvania. 




1893. 
GEORGE S. DAVIS. 

DKTROIT, MICH. 













Copyrighted by 

(iKORGE S. DAVIS. 

1893. 



THIS WORK IS DEDICATED, 
AS A MARK OF FRIENDSHIP AND RESPECT, TO 

J. WILLIAM WHITE, M. D., 

CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY 
OF PENNSYLVANIA. 



TABLE OF CONTENTS. 



IMPOTENCE AND SEXUAL WEAKNESS. 

Tage 
Anatomy and Physiology of the Sexual Organs — 

Organic Impotence — Psychical Impotence— Atonic 

Impotence : Irritative and Paralytic — Etiology, 

Diagnosis, Prognosis, and Treatment 1-74 

PROSTATORRHCEA. 

Origin, Symptoms, Prognosis, and Treatment 75-84 

INVOLUNTARY SEMINAL EMISSIONS. 

Nocturnal Pollution — Diurnal Pollution — Spermator- 
rhoea — Causes, Diagnosis, Prognosis, and Treat- 
ment 85-96 

IMPOTENCE OF THE FEMALE. 

Varieties — Congenital Anomalies — Local Inflammation 

— Displacements— Neuroses— Treatment 97-102 



IMPOTENCE AND SEXUAL WEAKNESS IN THE MALE 
AND FEMALE. 



Sexual weakness is an expression which conveys 
no clearly defined meaning; it implies that the 
sexual act is performed in an imperfect manner, the 
departure from normal being in the direction of defi- 
ciency. Under this general heading impotence 
would necessarily fall. 

The term impotence implies a lack of ability to 
perform the sexual act. It may be partial or com- 
plete. Impotence is not necessarily associated with 
sterility, nor on the contrary does sterility always 
imply even a moderate degree of impotence. Thus, 
many patients who have suffered from a double 
obliterating epididymitis and in whose seminal dis- 
charge no spermatozoa are found, are potent to a high 
degree; while some patients in whom the power of 
erection is totally lost may be able to discharge 
semen swarming with apparently healthy sperma- 
tozoa. 

Impotence in the male may be due to congenital 
or acquired deformity, or to absent or deficient 
erection. By far the large majority of impotent 
patients suffer from imperfect erection. 

In so far as the purposes of the present work are 



concerned, a brief consideration of the anatomy and 
physiology of the sexual organs is sufficient. 

The spermatozoa, or life-giving elements of the 
semen, are secreted in the testicles, pass into the epi- 
didymis, a minute canal twenty feet in length pro- 
vided with ciliated epithelium, and are carried from 
this tube by means of the vasa deferentia to the 
seminal vesicles and prostatic urethra. The vasa 
deferentia are about 24 inches in length, and are pro- 
vided with strong muscular walls for the purpose of 
propelling the semen towards the urethra. External 
to the vas of each side, and situated between the wall 
of the bladder and the recto-vesical fascia, lie the sem- 
inal vesicles. These form two bulbous masses of 
convoluted tubes, which may be considered as diver- 
ticula from the vasa deferentia, into the lumen of 
which they open at the back of the prostate. By 
the junction of the vasa deferentia and seminal vesicles 
are formed the common ejaculatory ducts, each about 
^ inch in length, much narrower than either of 
the channels which form it, and provided with ex- 
tremely thin walls. The common ducts traverse the 
prostate and open by slit-like orifices near the en- 
trance of the sinus pocularis or uterus masculinus. 

The urethra is a mucous canal about eight inches 
in length, surrounded throughout its entire length 
by muscular fibres and erectile tissue. 

The prostatic portion of the urethra is that part of 
the canal which lies in or upon the prostate gland. 



— 3 — 

It is about an inch and a quarter long, excepting the 
bulb, and is the widest and most dilatable part of the 
entire urethra. Upon its floor there is an elevated 
ridge, the veru montanum, projecting somewhat as a 
cock's comb and hence called the caput gallinaginis; 
this ridge is made up of muscular and erectile tissue, 
and during ejaculation prevents the backward flow of 
the semen into the bladder. The summit of this ridge 
is excavated in the middle line by a pouch about 
two-fifths of an inch deep and extending backward 
through the greater thickness of the prostate gland. 
This pouch is called the sinus pocularis. The slit-like 
openings of the common seminal ducts are found 
on the veru montanum to the right and left of the 
prostatic sinus. In the furrows on either side of the 
veru montanum are found the orifices of the prostatic 
ducts. The prostatic urethra is surrounded by an 
unstriped muscular layer, further reinforced by the 
muscular fibres which make up the greater part of 
the prostate gland. The nerve supply to this portion 
of the urethra is peculiarly rich. The superior rectal 
and vesical arteries send comparatively insignificant 
branches to the prostate; the veins are, however, 
generally large and anastomose freely. 

The prostatic urethra runs almost directly down- 
ward to the membranous urethra which passes down- 
ward and forward. This portion of the canal is about 
\ inch long, and is included between the anterior and 
posterior layers of the triangular ligament. It is 



surrounded by a thin layer of erectile tissue and by 
both involuntary and voluntary muscular fibres, the 
latter forming the compressor urethra? muscle. The 
membranous urethra is, with the exception of the 
meatus, the narrowest and least dilatable part of the 
canal. 

The penile or spongy urethra is six inches long 
and is surrounded by the erectile tissue of the spongy 
body. It exhibits two regions of physiological dila- 
tation, namely, at its posterior or bulbous part, just 
anterior to the termination of the membranous ure- 
thra, and at its anterior part just behind the meatus, 
the fossa navicularis. Into the lumen of the ure- 
thra open mucous crypts, the glands of Littre, es- 
pecially numerous in the pars bulbosa, and certain 
lacume, the largest one of which, termed the lacuna 
magna, is found in the roof of the fossa navicularis. 
The ducts of Cowper's glands open into the bulbous 
part of the urethra. These glands are each about 
the size of a pea and are placed beneath the mem- 
branous urethra, their ducts passing forward. 

The penis is mainly made up of erectile tissue, 
which is separated by means of fibrous investments 
into three irregular columns: the corpus spongiosum, 
containing the urethra and expanding to form the 
glans penis, and the two corpora cavernosa, forming 
the body of the organ and ending at about the position 
of the coronary sulcus, where they are capped by the 
glans. 



The corpora cavernosa arise from the pubic rami 
by strong fibrous processes called the crura, and are 
anchored to the pubic symphysis by a fibrous expan- 
sion termed the suspensory ligament. The crura are 
continued forward as two irregularly cylindrical 
bodies placed side by side. The walls of these bodies 
are made up of dense fibrous and elastic tissue. 
From these walls are given off many trabecule con- 
taining fibrous tissue and smooth muscular fibres. 
This gives the interior of the cavernous bodies the 
appearance of a sponge. Along the trabecule pass 
the arteries, which, either directly or by means of 
capillaries, pour their contents into the large spaces 
resulting from the formation of the parts. The 
spaces of each corpus freely communicate with the 
other, and in the anterior part of the penis there is 
only a very imperfect septum between the two cav- 
ernous bodies. 

The arterial supply to this series of venous sinuses 
is derived from the arteries of the corpora cavernosa 
and from the dorsal artery of the penis. Branches 
from these vessels penetrate through the outer fib- 
rous investment, pass along the trabecule, and 
either terminate as a capillary network, the branches 
of which open into the sinuses, or become greatly con- 
voluted forming the helicine arteries, and supply 
by their capillaries the trabecular structure. The 
blood from the cavernous spaces is returned by veins, 
the greater number of which pass directly back- 



— 6 — 

wards to join the prostatic plexus, while some pass 
into the dorsal vein of the penis. 

The corpus spongiosum occupies the same relation 
to the corpora cavernosa, as does the ram-rod to a 
double-barreled gun. It begins posteriorly in the 
bulb, a tuberous enlargement situated between the 
diverging crura and the corpora cavernosa, and ter- 
minates anteriorly at the glans penis. Its blood 
supply is derived from the arteries of the bulb. 

The muscles of the penis are the erector penis, the 
accelerator u rinse, and the unstriped muscular tissue 
surrounding the urethra and found in the trabecule 
of the erectile tissue. The erector penis passes for- 
ward from the inner surface of the tuberosity of 
the ischium, to be inserted into the sides and under 
surface of the unattached part of the crus. The 
accelerator urinse or bulbo-cavernous muscle arises 
from the central perineal tendon. Its two halves 
are united in a central raphe from which the fibres 
spread laterally, enveloping the bulb and spreading 
upward as a fibrous expansion over the dorsum of 
the penis. 

The mechanism of erection. When the arteries sup- 
plying the erectile tissue of the penis are in their ordi- 
nary condition, and when the unstriped muscular fibres 
of the trabecule are in a state of tonic contraction, 
thus to a great extent obliterating the venous spaces, 
the blood in its course has no tendency to overfill these 
spaces, but rather passes by the ordinary system of 



capillaries into the veins. Certain nerve fibres called 
nervi erigentes or erector nerves pass from the lower 
lumbar or upper sacral nerves to the vessels and 
muscular structure of the erectile tissue; these when 
stimulated cause dilatation of the arteries, hence an 
increased influx of blood, and relaxation of the 
trabecular muscles, hence lessened resistance in the 
venous spaces. As a result the spongy and cavern- 
ous bodies become turgid, enlarging in all direc- 
tions. In consequence of the swelling, the efferent 
veins passing along the trabecule and the fibrous 
investment of the spongy and cavernous bodies 
are pressed upon, and the congestion and blood 
pressure in the penis is increased. The return of the 
blood from the penis is still further prevented by 
contraction of the erector penis, compressor urethrse 
and accelerator urinse muscles. The penis is me- 
chanically carried up to an elevation beyond 45° by 
the action of the suspensory ligament, the erector 
penis or ischio-cavernosi muscles being particularly 
concerned in maintaining venous congestion, though 
by drawing downward and backward at the root of 
the penis they undoubtedly exert a distinct effect 
in carrying the point of the organ upward. 

The center for erection is placed in the lumbar 
region. Though stimulation of the erector nerves will 
produce a turgid condition of the penis, it will not 
occasion full erection, since, for the completion of 
the act, participation of the voluntary muscular fibres, 



— 8 — 

the ischio-cavernosi, the bulbo-cavernosi and the trans- 
versa perinei, is necessary. With all these factors 
working harmoniously the corpora cavernosa become 
of almost cartilaginous hardness. The corpus spong- 
iosum and its expansion, the glans, remain somewhat 
softer, because the investing fibrous capsule is less 
dense. When erection is completed, the blood re- 
turn from the penis may be still further obstructed 
by a voluntary muscular effort of the muscles of 
the penis and perineum, and the comparatively soft 
glans may be made to materially increase in size 
and become harder. The whole organ participates 
in this increase, but not to the same extent as the 
glans. An atonic condition of the perineal muscles 
prevents complete vigorous erections. 

Emission. The epididymis with its coni vasculosi 
acts as a reservoir for the spermatozoa, which, when 
they fill this space, pass into the vas and are 
carried by the peristaltic action of the muscular coat 
of this tube to the vesiculae seminales. Incident with 
erection the testicles are drawn close to the external 
rings. It is probable that the muscular coats of the 
vas act with more than usual vigor. As a result of the 
afferent impulse carried from the nerves of the glans 
the common ejaculatory ducts become patulous and 
the contents of the seminal vesicles is passed into 
the prostatic urethra. The muscular substance of 
the prostate contracts, squeezing out the secretion 
from its own follicles to be mixed with the sperma- 



tozoa and secretion of the seminal vesicles. As a 
result of this contraction, and the simultaneous relax- 
ation of the compressor urethrse, the combined 
secretions is forced into the bulbous urethra, since 
the turgid veru montanum prevents it from being 
forced backward into the bladder. From here it 
is driven forward by clonic contractions of the 
accelerator urinas, aided by the entire perineal 
group and by the unstriped muscular fibres of the 
urethra. The muscular contractions pass forward 
as a wave and are repeated till all the semen 
is ejaculated. It is probable that the first volup- 
tuous sensations are associated with the ejaculation 
of the semen into the prostatic urethra and the con- 
traction of the muscular substance of this gland for 
the purpose of driving the semen and its secretion 
forward, since ejaculation does not immediately 
follow the first contractions. 

Slightly before the orgasm Cowper's glands dis- 
charge their contents into the bulbous urethra; this 
act is accompanied by sensations which are usually 
unnoticed, since they precede the orgasm by such a 
slight interval that they are unnoticed or forgotten 
in the greater nerve impression. I have seen patients 
who could produce this discharge from Cowper's 
glands without the emission of either the prostatic 
or testicular secretion. 

The semen is made up of the secretion of the tes- 
ticles, the seminal vesicles, the prostate, Cowper's 



— 10 — 

glands and the urethral crypts and follicles. When 
first ejaculated it is a thick gray fluid with an odor 
somewhat like a raw potato. It shortly becomes 
gelatinous, but after further exposure to the air for 
ten to twenty minutes becomes liquid. If allowed to 
stand, there settles from it a white layer of sperma- 
tozoa, above which lies a gray, translucent liquid. 
These two layers should, according to Ultzmann, be 
of equal bulk in normal semen. The spermatozoa 
should live from twelve to twenty-four hours after 
the semen has been ejaculated, provided it is kept 
warm and has not been allowed to evaporate. In 
the latter case the addition of a mildly alkaline sol- 
ution will often restore motion to spermatozoa which 
are apparently dead. When the semen is deposited 
in the female genitalia, spermatozoa are found living 
for upwards of a week. After standing for two or 
three days, spermatic crystals are deposited. 

The amount of semen discharged as a result of one 
orgasm is about two drachms, though after long con- 
tinence double this quantity may be ejaculated, or 
when repeated drains are made on the strength only 
a few drops may appear. 

The erectile centre may be stimulated to transmit 
an impulse through the nervi erigentes, either from 
the brain; from direct irritation; from the spinal 
cord; from the prostatic urethra, or other parts 
of the sexual apparatus; or from the anus or other 
regions under the domination of an associated nerve 
plexus. 



— 11 — 

The centre for erection in the cord is undoubtedly 
under the domination of the vaso-dilator centre in 
the medulla oblongata, fibres within the cord making 
the communication. Psychical impressions have a 
marked influence upon the vaso-dilator nerves, a com- 
mon example of this influence being offered in the flush 
caused by anger or shame, the dilatation of the blood- 
vessels of the head being due to stimulation of the 
vaso-dilator fibres; by a similar mechanism, when the 
thoughts are strongly directed towards sexual sub- 
jects, there results a powerful action upon the nervi 
erigentes. Thus sights, sounds, odors, memories, in 
fact all mental impressions which suggest sexual 
desire, may produce powerful erections. 

As examples of erections due to direct spinal irrita- 
tion, may be mentioned those which sometimes occur 
in the early stages of disease of the cord or those which 
are noted after injury. When this injury is inflicted 
high up, the priapism which occurs is due to a cutting 
off of the inhibitory fibres rather than to direct irri- 
tation of the centre. 1 



1 I have recently had under my care a young man with 
fracture of the spine in the dorso-lumbar region with com- 
plete paraplegia ; there was partial control over the bladder and 
rectum. For three weeks after the injury his penis was con- 
stantly in a condition of priapism. This gradually subsided 
and was followed by a rather rapid atrophy of the testicles, 
which at the present time are no larger than those of a child 
of ten or twelve years, although the penis is of normal size. 



— 12 — 

Erection is excited by peripheral stimuli. Thus the 
priapism which sometimes occurs as the result of 
mechanical friction while riding horseback; the con- 
tinued erections often associated with prostatic cal- 
culus or inflammation of this part of the urethra; the 
erections associated with full bladder, are examples 
of reflexes arising from the sexual organs. 

Erections excited by stimulation of associated 
fibres are instanced by the priapism which occurs in 
children on examination of the hip, or the erections 
due to flagellation of the buttocks, or those asso- 
ciated with inflammatory or irritative conditions of 
the anus and rectum. 

Before considering the question of impotence, it is 
well to determine what may be considered a normal 
amount of sexual strength. Individuals vary so in this 
respect that it is impossible to set a standard. Per- 
haps it is fair, however, to state, that a man, between 
his twentieth and fiftieth year, who is not over- 
worked or unduly harassed, who is in good physical 
condition, and who has the proper and legitimate 
degree of sexual excitement, should be able to have 
intercourse on an average of twice a week (the act 
lasting from three to five minutes before ejaculation), 
and should not experience as an after-result a sense 
of fatigue or exhaustion. 

It must be clearly recognized that everything which 
tends to lower vitality, such as anxiety, excessive 
work, bodily or mental, insufficient food, impaired 



— 13 — 

health, the alcoholic and tobacco habits, may render 
an indulgence to the extent above mentioned dis- 
tinctly injurious, or even quite impossible. 

Per contra, those of exceptionally vigorous consti- 
tution and particularly those who live much in the 
open air may quite safely far exceed the limit given. 
It must also be recognized, that power and desire are 
not always commensurate, and that, particularly in 
the case of brain workers, the latter is liable to be 
greatly in excess of the former. 

The power of erection begins at birth and departs 
usually from the sixty-fifth to the seventieth year, 
though sometimes it continues much longer, there 
being many recorded cases of men who up to their 
eightieth or even ninetieth year have full powers of 
intercourse, and are apparently able to beget. I have 
seen one man, aged seventy-eight, an observer of 
the laws, and apparently a lover of truth, who, 
marrying a young woman, became in due time the 
father of a child. In his eightieth year he stated, 
that since his marriage he had performed the sexual 
act every night, excepting at such times as the con- 
dition of his partner made it impossible. He noticed 
no change in his power except for the fact that 
emission was delayed. I have also seen a child less 
than one year of age who masturbated and appar- 
ently experienced an orgasm, or at least some form 
of nervous crisis. 

A consideration of the physiology of erection and 



— 14 — 

ejaculation suggests, as a reasonable clinical classi- 
fication of the forms of impotence, the following: 

1. Organic Impotence. 

2. Psychical Impotence. 

3. Atonic Impotence. 

Organic Impotence. — This form of impotence 
may be due to either congenital or acquired central 
changes affecting the cord and lumbar centres, or the 
afferent or efferent nerve fibres communicating with 
the erector centre. 

In the vast majority of the cases falling under 
this head, impotence is due to malformation of the 
external genitalia. This malformation may affect 
the penis or the testicles, or both these organs, as 
in cases of hypospadia; or with perfectly healthy 
genital organs, malformation may affect the sur- 
rounding parts in such a way that sexual congress 
is impossible. 

The pei as may be completely absent, may exist only 
as a rudiment, or may be deformed. 

If the penis is absent or exists only as a rudiment, 
the impotence is absolute and incurable. 

If the organ is present and normal, excepting in 
regard to size, even though it is exceedingly small, 
the patient is not necessarily impotent. Indeed, 
one case is quoted by Roubaud in which an organ 
but two inches long and of the circumference of a 
quill was by a mechanical device rendered service- 



— 15 — 

able. In the case of this young man sexual con- 
gress was not followed by ejaculation, and although 
both desire and erection were well developed, he was 
able to experience emissions with their coincident 
sensations only by means of masturbation. 

Roubaud fitted this stunted organ with a rubber 
cylinder the size of an ordinary penis. Into the in- 
terior of this the erect penis was introduced. The 
apparatus was held in place by an elastic band 
passing around the back. The movements of copu- 
lation, when this apparatus was in place, were sufficient 
to excite ejaculation. As a result of this treatment 
the organ increased considerably. 

In Wilson's case, a man of twenty-six, whose gen- 
ital organs were not more developed than those of a 
child of eight years, after two years of married 
life and physiological activity there was complete 
restoration to the normal size. 

The practical point to be remembered in the con- 
sideration of these cases of arrested development 
is, that treatment may be followed by satisfactory 
results. The application of an apparatus which 
tends to produce venous congestion has in some 
cases, it is alleged, been followed by satisfactory 
results in so far as growth is concerned. Such an 
apparatus consists of a chamber into which the penis 
can be introduced, and from which the air can be 
partially exhausted. As a result it is daimed that an 
augmentation in volume takes place, which, on con- 



— 16 — 

tinuing the treatment for weeks or months, is 
permanent. In many cases considerable increase in 
the size of the organ has been noted in the first years 
of married life. 

Enormous size of the organ sometimes renders 
intercourse impossible, excepting under especially 
favoring circumstances. For such a condition sur- 
gical treatment would scarcely be required. 

Adhesions of the penis and the scrotum may 
occasion impotence; this is relieved only by plastic 
operation. 

The distortion of the penis, such as is constantly 
found in hypospadias, that is, a downward curve, 
may prevent intercourse. Such distortion may also 
result from wounds or from the contraction of 
cicatrices. It may be remedied by cutting a wedge- 
shaped piece from the convexity of the deformed 
organ and apposing the raw transverse sections of 
the corpora cavernosa by deep sutures. Though this 
will straighten the organ it is very liable to inter- 
fere with perfect erection, the cavernous bodies 
anterior to the point of section remaining more or 
less flaccid while the rest of the organ is rigid. 

Fibrous, cartilaginous, or gummatous indurations 
of the erectile tissue or the fibrous sheath of the 
penis may cause great distortion of the organ, and 
may render coitus difficult or impossible, since erec- 
tion to the distal side of such indurations is exceed- 
ingly feeble. Fibrous induration is commonly found 



— 17 — 

associated with rheumatism and gout. It is not in- 
frequent after gonorrhoea, and is by some authors 
ascribed to syphilis, though, excepting in the case of 
unmistakable gummata, this relation has been vigor- 
ously contested by Mauriac. 

The treatment required is constitutional, depending 
upon the diathesis with which the lesion is associated. 
Gummatous deposits often yield to specific treatment, 
but the indurations associated with gonorrhoea or 
gout, or ascribable to no local or general cause, are ex- 
ceedingly obstinate. Local treatment is of little ser- 
vice. Inunctions of mercury ointment should be 
used, however, and the beneficial resolvent effects 
of heat, moisture and pressure should be secured by 
the application of a thin rubber bandage to the 
penis. 

Aneurismal dilatation of the corpora cavernosa, 
sometimes congenital, sometimes due to violence, 
may form a tumor which may offer mechanical ob- 
struction to the sexual act so great as to entirely in- 
hibit its performance. 

In such cases the application of rubber supports or 
bandages will usually give temporary relief. 

Congenitally acquired shortness of the frenum or 
varix of the dorsal vein of the penis may also cause 
impotence. Section of the one and excision or liga- 
tion of the other will relieve the disability. 

Swellings of the external genitalia, such as is 
observed in elephantiasis and oedema, or enlargements 



— 18 — 

and projection of neighboring parts, as in large 
herniae, scrotal tumors and overhanging belly, all 
may occasion impotence by rendering impossible 
intromission of the penis, even though this organ be 
of good size and capable of healthy erection. 

Certain malformations and diseases of the testicle 
also occasion impotence; in this case from lack 
of power to obtain erections, for the penis is at times 
of full size. Thus absence of the testicles, or anor- 
chidism, is always associated with impotence. Crypt- 
orchids, or those in whom the testicles are retained 
in the abdomen or groin, are usually potent, although 
they often are sterile. The removal of both testicles 
is always followed by impotence. This may not result 
for a number of years, Cooper quoting a case in 
which intercourse was practised nine years after such 
an operation, though there was progressive loss of 
sexual strength. 

Destruction of the testicles as the result of inflam- 
matory processes, is destructive of virility. Orchitis 
secondary to mumps very commonly goes on to the 
stage of atrophy. If both testicles have been involved 
in the process, impotence will result. The epididy- 
mitis secondary to gonorrhoeal urethritis is not an 
inflammation of the testicle, the secreting structure 
of this gland being spared; hence, even though both 
sides be affected by this form of inflammation, im- 
potence will not result, though the patient may remain 
absolutely sterile. 



— 19 — 

Tumors, and tubercular and syphilitic infiltration 
of the testicle, passiye congestion dependent on 
varicocele, when involving both testicles, are often 
associated with absolute impotence. Even though 
one testicle is involved, the other remaining healthy, 
the patient is frequently impotent. This is especially 
true of the tubercular lesions, possibly because when 
they appear in the testicle, they have already as a 
rule invaded the prostatic urethra. I have recently 
seen a powerful man, who, following a tubercular 
involvement of his right epididymis, has been impo- 
tent for 12 years. The tubercular process has become 
encysted; the man seems to be perfectly healthy, but 
he never has normal erections. 

Psychical Impotence. — This form of impotence 
implies well formed sexual organs with full power of 
erection, but with this power not under the control of 
the will. Patients suffering from psychical impo- 
tence usually have exceedingly vigorous erections 
occasioned by lascivious thoughts, by a full bladder, 
or by any of the causes which are sufficient to 
excite the centre for erection. When, however, 
opportunity for sexual intercourse is given, there is 
either an imperfect erection or, in place of enlarg- 
ing, the penis may actually become smaller than in 
its ordinary flaccid condition. 

The usual cause for this is timidity, and the condi- 
tion is observed in its simplest form in those whose 



— 20 — 

lives have been most chaste. The nervous, highly- 
strung man, innocent of sexual matters, who recol- 
lects with shame and horror the period when he in- 
dulged to a greater or less extent in masturbation 
— shame indissolubly connected with the act; horror 
from the fancied consequences, which the lurid com- 
mercial literature on tbis subject assures him will 
surely follow — will experience, in addition to the per- 
turbation incident to his new experience, the power- 
ful anaphrodisiac of fear lest his first attempts posi- 
tively demonstrate the sexual weakness begotten by 
his early habits. 

Even without this element of fear, in those of 
sensitive organism, the conditions of early married 
life are not adapted to the fullest stimulation of the 
sexual instinct. Under such circumstances erections 
may be conspicuous by their absence. If the ele- 
ment of distrust and fear were absent before, after 
one failure it is present in full force, and is often 
sufficiently strong to render subsequent approach 
equally unsatisfactory. 

Although psychical impotence is most often ob- 
served in the aesthetic recluse or the chaste farmer, 
those of looser morals do not always escape. The 
mental effect is produced somewhat as follows: 
After some months, or possibly years, of life about 
town, the youth who has heretofore stopped short of 
sexual congress, finally, when well under the in- 
fluence of liquor, yields to temptation, but finds him- 



— 21 — 

self unable to complete the act. In this case the 
inhibitory influence of rum has produced a tempor- 
ary condition which the patient is prone to regard as 
permanent, and, even should he make his next at- 
tempt under more favoring circumstances, he is liable 
to meet with disappointment from distrust in his 
powers. 

Many men of lively temperament are chaste from 
the fear of disease, unfortunately the most potent 
factor in maintaining virtue. This finally gives way 
to a more than usual] } r severe temptation. At the 
very time when such thoughts should be banished 
from the mind, the old fear returns with redoubled 
vigor, producing its characteristic physical effect, and 
subsequently begetting in the patient a condition of 
distrust as to his sexual powers, highly desirable so 
long as he remains single, but often so deeply rooted 
as to be productive of much distress should he decide 
to marry. 

Sometimes the circumstances under which fornica- 
tion is undertaken are such as to render the perform- 
ance of the act difficult. Necessity for haste; fear of 
discovery; a dozen different causes may render the 
man quite unable to perform his part. One failure in 
men of neurotic temperament strongly predisposes to 
another. 

In some cases remorse is sufficient to prevent erec- 
tion, and to produce a profound mental impression 
from which the patient with difficulty rids himself; 



— 22 — 

usually, however, this emotion i6 not experienced 
till its workings are of little immediate practical 
value. Disgusting sights or odors have begotten a 
psychical impotence which has proved difficult to 
overcome. 

I have seen patients who were so shocked by the 
appearance of vermin or of filth on or about the 
woman toward whom they made their first approaches, 
that passion was at once subdued, and though subse- 
quently excited by other and more attractive objects, 
and under more favorable circumstances, was no 
longer accompanied by a satisfactory amount of 
power. 

As an instance of some of the forms of psychical 
impotence the following case may be cited. A. B., 
an exceptionally healthy and vigorous man, aged 23, 
consulted me for impotence. His sexual organs 
were well formed; he suffered from nocturnal emis- 
sions about once in six weeks. Examination of his 
emission on one occasion proved it to be swarming 
with seemingly healthy spermatozoa. In the morn- 
ing he woke with vigorous erections, and strong 
erections were excited by sights or stories calculated 
to produce this effect. On four different occasions 
he attempted intercourse, in each case with women 
of the town, and on all four occasions was entirely 
unable to have an erection. 

This patient was advised to make no further trial 
until after his marraige, which was then impending, 
and to make no trial at intercourse for two weeks 



— 23 — 

after that date. He subsequently regained complete 
control of his sexual powers, although the directions 
in regard to his post-marital conduct were not strict- 
ly observed. 

II. A. B., an unusually powerful man, much given 
to promiscuous fornication, was suddenly surprised 
when about to have sexual relations with a young 
woman of supposed respectability. His erection im- 
mediately subsided, and did not recur for many 
months. One year after, he had morning erections 
and occasionally those excited by mental impressions 
calculated to produce this effect. He has not yet, 
however, recovered his full sexual power, every at- 
tempt at intercourse proving abortive. The penis, in 
place of becoming erect, seems to shrivel to about 
half its normal size. 

III. A. B., a strong man of 25, indulged for some 
years in every form of dissipation, excepting forni- 
cation. After a heavy drinking bout, he passed the 
night with a woman of the town. In the morning 
she told him that he had unsuccessfully attempted 
fornication. He recollected nothing of the night, 
but was then absolutely without erection or desire, 
and only anxious to escape from the house. 

In thinking of the matter afterward, the statement 
of the woman produced a powerful impression upon 
his mind. He fancied that he was suffering from 
impotence, and to determine this question he made 
several trials, in each case unsuccessfully. His morn- 



— 24 — 

ing erections were powerful, his sexual apparatus 
perfectly healthy; and as soon as the true nature of 
his case was explained to him, his convalescence was 
rapid and complete. 

There is also a form of psychical impotence, rare 
certainly, but none the lef-s existing, dependent upon 
almost total want of desire. 

For such persons women offer very slight attraction. 
Their erections may be normal, but the pleasure in- 
cident to sexual relation is so slight that it offers no 
adequate compensation for the trouble necessary to 
obtain it. 

There are certain patients in whom the psychical 
impotence is relative. That is, with some women 
they may be exceptionally vigorous, with others 
their powers may be slight or altogether wanting. 

It is undoubtedly true that, as a rule, educated and 
refined women are less passionate than men; indeed, 
I think this may be said of women of every degree. 
Their desire for sexual congress is less; and many 
wives, laudable in all respects, are not the sexual 
equals of their husbands. To such women sexual 
approach is sometimes a matter of total indifference; 
sometimes disagreeable; occasionally painful or re- 
volting. To some men this mental attitude is suf- 
ficient to render the sexual act impossible. In ad- 
dition the flabby vulva, the relaxed vagina, the 
passive reception of the approach, does away with 
the local stimulus which is such a powerful aid 



— 25 — 

to the proper completion of the sexual act. It is, 
unfortunately, with their legitimate partners that 
men are most frequently not in sexual accord. 

Even though women may be well fitted to play 
their part in the sexual act, men will be encountered 
to whom intercourse is impossible save with certain 
individuals. Thus, I saw one patient who was never 
able to secure an erection except when in the company 
of a woman of a certain complexion and stature. He 
asserted that in early life he loved and intended to 
marry a woman of this type; none other had ever 
caused in him sexual excitement. 

Those sexual perverts may also be considered 
impotent, who have no desire for the possession of 
women in the carnal sense, but who find their pleas- 
ure by caressing objects of women's apparel or locks 
of their hair; in simply looking at them and imagin- 
ing the circumstances of a sexual relation. To this 
class would also belong men who desire their own sex, 
or whose desires lead them to unnatural practices 
with beasts. 

The treatment of psychical impotence will be suc- 
cessful in its issue in accordance with the power of 
the physician to make upon the mind of the patient 
a strong impression. It is perfectly futile to dismiss 
such patients with a few words of good advice. 
They have suffered for months or even years from a 
condition which has preyed upon their minds and 
often has altered their entire characters. They come 



— 26 — 

with fixed beliefs; with a conviction as to the organic 
nature of their weakness so profound, that no argu- 
ment is sufficient to shake them out of it. They 
are usually well assured that they are impotent 
on account of distinct lesion or because of the wear- 
ing out of that portion of the nervous system which 
presides over the function of erection and ejacula- 
tion. In the great majority of cases they attribute 
this to masturbation, since this is practised to a 
greater or less extent by nearly every boy at one time 
in his life. These patients usually postpone seeking 
advice till driven to desperation by the mental suf- 
fering which their condition entails. They consent to 
make what they consider their shame known on the 
chance that medical help may serve them. An over- 
wrought, hysterical, hypochrondrical patient is not 
to have his habits of thought, his profoundest con- 
victions, brushed aside with a few words. If he is 
sensible he will not be content with one or two 
dogmatic assertions; if he is foolish he will neither 
understand nor remember them. He must be con- 
vinced that his case has been carefully studied, and 
must be made to believe that a rational and probably 
successful treatment has been instituted. 

Before making a diagnosis as to the nature of 
psychical impotence, an accurate and careful history 
of the entire case should first be taken. This will 
throw much light, not only on the cause and the true 
nature or extent of the weakness, but will also give 



— 27 

the surgeon an insight into the mental processes of 
the patient. This history should include the patient's 
routine of living; the amount of exercise he takes; 
the regularity with which he takes his meals; the 
condition of his stomach and bowels; his hours of 
sleeping and of waking; and the presence or absence 
of rheumatic, gouty or scrofulous tendencies. More- 
over from the history may be learned whether the 
patient is hereditarily neurotic; whether his sexual 
weakness depends upon abuse of tobacco, alcohol, 
or other drugs; whether it is due to general debility 
consequent to exposure; or to acute diseases such as 
diphtheria. 

This should be followed by a thorough examina- 
tion — not only a local examination as to the sexual 
weakness, but a general examination of the condition 
and functional activity of all the important organs 
of the body. The condition of the heart and lungs 
must be determined; functional or organic alterations 
of the central nervous system must be excluded; the 
quantity and quality of the urine must be determined; 
the anus should also be examined to determine the 
presence or absence of a cause for reflex irritation. 

The penis and testicles must be examined care- 
fully. The condition of the entire urethra is deter- 
mined by means of sounds and bulbous bougies. A 
finger passed into the rectum can readily palpate the 
prostate gland, and determine the presence or ab- 
sence of gross lesions. 



— 28 — 

If the case be one of entirely psychical impotence, 
such an inspection will show the absence of local 
lesions. 

The examination having been completed, it is well 
to inform the patient that there is nothing organ- 
ically wrong, that the disease is entirely curable, 
that he can confidently hope for restoration of his 
powers. It may be taken for granted that he has 
read to a greater or less degree the errors-of -youth 
and manhood-restored literature, so widely circulated 
by charlatans for the purpose of extorting money 
from this very class of patients. It is, therefore, advis- 
able to explain the misleading nature of these writ- 
ings. 

These patients should always be given medicine; 
sometimes this medicine is of great value. Thus, 
examination of the urine may show the oxalic dia- 
thesis, which will be corrected by diet and by nitro- 
muriatic acid or other appropriate remedies; or there 
may be great excess of uric acid, to be remedied by 
appropriate diet; or the bowels may be torpid, and may 
be stimulated to activity by the exhibition of strych- 
nia and belladonna or other drugs; or digestion may 
be feeble and will be helped by pepsin and hydro- 
chloric acid and by tonics. If there is no distinct 
indication for medication, a general tonic may be 
ordered; such as compound syrup of the hypophos- 
phites, or compound tincture of cinchona, or wine 
of coca and celery. 



— 29 — 

If the patient has been recently married, it is well 
to tell him that a medicine will be given which will 
act as a powerful sexual excitant; at the same time 
some words of advice are offered as to the time and 
method of approach. Perhaps the best stimulating 
medication in these cases, is a pifi made up of ex- 
tract of damiana 2 grains, phosphorus y^ of a grain, 
strychnia -^V of a grain. This is to be admin- 
istered three times a day, and an added dose may 
be taken at night. The patient is advised against 
attempting intercourse for six nights after he begins 
taking the medicine, and is told that when he does 
attempt congress, advantage should be taken of the 
morning erection, and the act should be instituted as 
promptly as possible, without preliminaries or delay 
of any kind. 

The treatment of those who are unmarried should 
be conducted on somewhat different lines. Although 
it is true that the great majority of single men past 
eighteen seek and find sexual gratification, it is not a 
part of the physician's duty to order this as a treatment, 
nor do I think it is ever necessary. In such cases a 
general treatment, including rigorous exercise and 
cold bathing, should be supplemented by the pa'ssage 
of instruments. The introduction of the cold sound 
or the urethral electrode into the prostatic urethra 
will often be followed by immediate and vigorous 
erections, in themelves a source of infinite comfort 
to the patient, since he fancies that a response on the 



— 30 — 

part of the penis to a mechanical insult of this kind 
is a certain sign of pristine vigor. 

These patients must be especially cautioned against 
trials to discover whether or not their power is re- 
stored. The women they usually seek, animated only 
by mercenary motives, often poorly feigning pas- 
sion they never feel, are neither physically nor men- 
tally attractive, and are ill calculated to develop 
power which the patient fancies he has lost. Under 
favorable circumstances such patients can confidently 
expect to find themselves completely potent; and 
with this assurance and with careful treatment 
designed to improve the general health and to create 
a feeling of confidence as to sexual power, the physi- 
cian must rest content. 

For cases of relative impotence, that is, inability to 
perform the sexual act with certain females, little can 
be done. Each individual case must be managed on 
its merits; in each case the physician must act wisely 
and for the best interests of morality; then, if his 
counsel and treatment accomplish no good, he is 
at least spared the regret of having left affairs in a 
worse condition than he found them. In these cases 
a word to the woman sometimes may be productive 
of good. 

Stimulation of the sexual centres, either directly 
or by alcohol, strychnia, phosphorus, and damiana, 
or reflexly by cantharides, may, at times, be of 
temporary benefit. Rich food, pure air, and shun- 



— 31 — 

ning the society of other women for a long period, 
will accomplish more than any other method of treat- 
ment. 

Atonic Impotence. — This term implies such a 
weakening of the lumbar centres for erection and 
ejaculation that these functions are no longer per- 
formed in the normal manner. 

This condition of the reflex centres is usually de- 
pendent upon a hypertonic or inflammatory condition 
of the prostatic urethra. In consequence of hyperee- 
mia and inflammation, the efferent nerves which are 
so richly distributed through this portion of the ure- 
thra, and particularly to the veru montanum, are 
hypersensitive. As a result the lumbar centres are 
kept in a condition of constant irritation, inevitably 
resulting in exhaustion, as shown by the imperfect 
functional performance of the parts presided over by 
these centres. 

At times the excitability of the genito-spinal cen- 
tre is abolished quite independently of any abnormal 
condition of the posterior urethra. 

Certain general conditions, such as anaemia, either 
idiopathic or due to any of the various cachexias, 
diabetes, acute rheumatism, uraemia, cola?mia, are 
often accompanied by loss of sexual power. Fortun- 
ately in these cases the desire fails with power. 

Not infrequently after diphtheria temporary impo- 
tence may be the first sign of subsequent paralysis; 
sometimes it may be the only manifestation. 



— ;?2 — 

Many drugs, if taken until toxic effects are pro- 
duced, cause complete impotence. Saturnine intoxica- 
cation is frequently accompanied by anaphrodisia and 
impotence. Carbonic acid gas, after the immediate 
poisonous effects have passed off, sometimes leaves 
the patient in a condition of complete impotence. 
Fodere cites the case of a man who was unable to 
have connection for six months after recovery from 
an attack of poisoning of this kind. Bisulphide of 
carbon and antimony are also said to have produced 
anaphrodisia and loss of power in those whose work 
required them to breathe an atmosphere containing 
traces of these drugs. 

Alcohol and tobacco claim the most victims. ^The 
former drug, stimulating in small doses, when long 
continued, destroys power and usually desire. In the 
case of both these drugs, the effect often long out- 
lives the continuance of the bad habit. Months or 
even years may be required before power is regained. 

Certain individuals exhibit an idiosyncrasy toward 
tobacco so that a comparatively small dose is suffi- 
cient to destroy their sexual powers, even though it 
produces no other appreciable injurious effect. Cig- 
arettes, particularly when their fumes are inhaled, 
are credited with exercising a more sinister effect 
than tobacco used in other forms. 

It cannot be stated as a rule that among those 
working in tobacco factories there is any loss of sex- 
ual power. It is believed that this is because their 



— 33 — 

life is so arranged, that more than usually favor- 
able opportunities are offered and possibly an artifi- 
cial stimulus provided. This very fact would, how- 
ever, make more apparent failing sexual power. Cer- 
tain individuals in such factories will, however, seek 
advice on account of impotence, and in them it is 
always possible that their malady may be due to 
idiosyncrasy toward this powerful drug. 

Trousseau says that coffee is a powerful anaphro- 
disiac, and of itself is able to produce complete 
impotence. It is quite certain that this drug taken 
in enormous doses may produce such an effect, but 
rather because of the general nervous break-down it 
produces than from any direct effect upon the 
sexual organs. In ordinary doses, that is, one or two 
cups a day, and to those who exhibit no idiosyn- 
crasy, the effect of this drug is rather stimulating. 

Many drugs when given in physiological doses will 
temporarily lessen sexual power. Among these the 
bromides are particularly potent, and cocaine is also 
stated to possess this power. Morphia in full doses 
is operative only in certain individuals. Like tobacco, 
when used habitually and to excess it abolishes both 
desire and power. 

The treatment of impotence dependent upon gen- 
eral conditions, such as post-pyrexial adynamia, anae- 
mia or toxa?mia, must be conducted on general prin- 
ciples. When the general health is restored the sex- 
ual impotence will disappear. Drug impotence will 

8 



— 34 — 

be cured when the cause producing it is removed; 
but the restoration in these cases may be very slow. 
Atonic impotence may be classified in accordance 
with its clinical symptoms as follows : 

1. Irritative form. Erections may be complete ; 
they are often imperfect. Emissions are always pre- 
mature, often occurring immediately on contact. The 
sexual desire is usually strong. 

2. The paralytic form. Erections are absent, or 
at the most are extremely feeble; desire is wanting; 
ejaculation occurs with little or no pleasure, semen 
dropping from the flaccid penis. 

The irritative form of impotence, i. e., that char- 
acterized by premature ejaculation, with or without 
feeble erection, is by far the most frequent. The 
cause of this form of impotence is nearly always a 
diseased condition of the prostatic urethra, the mu- 
cous membrane being either hyperaemic or actually 
inflamed. This condition of the prostatic urethra 
may depend upon a number of causes. Among these 
may be mentioned the following: (1) Gonorrhceal 
inflammation and its sequel, stricture; (2) Prolonged 
and ungratified sexual excitement; (3) Excessive 
venery; (4) Strongly acid or irritating conditions of 
the urine. 

Of these causes gonorrhozal inflammation with its 
commonest sequel, stricture, is by far the most fre- 
quent. After this would be placed in order of impor- 



— 35 — 

tance, excessive venery, including under this heading 
onanism; prolonged and ungratified sexual excite- 
ment, the victims from this coming mostly from 
country regions; and, finally, irritation from the 
urine. 

Atonic impotence from gonorrhceal inflamma- 
tion. — Acute gonorrhoea commonly involves the 
prostatic urethra, but subsides promptly and com- 
pletely. In a certain percentage of cases the pros- 
tatic urethra becomes acutely inflamed, producing 
symptoms quite as distressing as those which accom- 
pany inflammation of the anterior portion of this 
tube. In addition to urgency and frequency of 
urination, there is often distressing tenesmus, and a 
few drops of blood will be discharged at the end of 
each act of micturition. These symptoms subside 
in a few days, but continue with more or less severity 
for some months, being awakened to new activity 
from time to time by exposure to cold, indulgence 
in alcohol, sexual excesses, or other imprudence. 
The discharge from the penis ceases entirely between 
apparent relapses; the patient regards himself as 
cured, and suffers only from increased frequency of 
urination and an occasional subacute attack of 
what he is usually told is cystitis. Examination of 
the urine will show, however, that pus is always 
present. 

As a consequence of this long-continued irritation, 
the mucous membrane of the prostate undergoes the 



— 36 — 

changes characteristic of chronic catarrh. The ter- 
minal sensory nerve filaments are involved, and re- 
flexly keep the centres for erection and ejaculation 
in a condition of hyperesthesia. Frequently this 
chronic catarrh runs on to a condition called prosta- 
torrhoea. In this case the patient complains of dis- 
charge of prostatic fluid during defecation, after urina- 
tion, and during erection, when sufficient stimulus for 
ejaculation is not applied. 

Chronic inflammation of the prostatic urethra may 
be kept alive by simple persistence of gonorrhoeal 
inflammation, or perhaps more frequently by the 
formation of a stricture in the membranous or pos- 
terior portion of the penile urethra. The relation of 
stricture to impotence has been well shown by many 
reported cases. The mechanical obstruction offered by 
stricture even of large calibre, is sufficient to indefin- 
itely prolong an inflammation behind the point of 
narrowing, when this has once started. 

Atonic impotence from sexual excess is probably 
more frequent than the histories of cases would lead 
the surgeon to infer. This is because men and boys 
are notoriously untruthful in regard to the amount of 
their sexual indulgence. Some, and usually those with 
the smallest powers, and who exhibit these powers 
most moderately, narrate experiences before which 
the records of the wildest satyriasis pale. Others 
cursed with violent and unchecked passions, are, ac- 
cording to their accounts, moderate to an extreme. 



— 37 — 

It is particularly in those who practise self-abuse that 
the form of impotence due to sexual excess is found. 
With these unfortunate patients, an admission as to 
the extent to which they yield to temptation is al- 
most never obtainable. In a fairly extended experi- 
ence I have known of but one instance where the 
patient frankly acknowledged that he still continued 
the habit and was unable to conquer it. 

The question has often been raised as to whether 
masturbation affects the general system more injuri- 
ously than sexual intercourse, if both be practised to 
the same extent. This is a difficult question to 
answer, since the conditions of comparison are 
practically impossible of fulfilment. There is a wide- 
spread belief not only in the community, but among 
the doctors, as to the disastrous effects produced by 
masturbation per se. There is a constant tendency 
to refer back to this practice many or all of the ills 
which arise during the course of a lifetime. Dis- 
eases of the genito-urinary organs are peculiarly 
liable to be considered as dependent upon onan- 
ism — justly in some cases, no doubt. Hence, while 
the number of people who attribute their ills to 
masturbation is legion, those who complain of the 
results of excessive sexual gratification are com- 
paratively few. Immoderate indulgence in sexual 
intercourse requires the consent of another person, 
and, as a matter of fact, marks for its victims, at 
least in so far as immediate consequences are con- 
cerned, a comparatively small number of patients. 



— 38 — 

The excesses of the libertine are usually paroxys- 
mal, and are associated with inordinate use of stimu- 
lants, the general effect of which quite overshadows 
the results from undue sexual activity. Among the 
men-about-town impotence is rare, except that form 
resulting from gonorrheal inflammation and its results. 
Occasionally, however, after an unusually prolonged 
debauch, patients will appear complaining of feeble or 
absent erections. It is always a question in these cases 
as to whether this is the result of tobacco and rum, 
or is due to sexual excess. 

The ultimate effect of sexual excess seems to be 
the institution of certain sclerotic changes in the 
cord, resulting in locomotor ataxia and kindred dis- 
orders. When these changes occur, impotence 
shortly becomes complete. 

The following is a typical case of temporary im- 
potence from over-activity. 

A. B., aged 30; married ten months; had syphilis; 
never suffered from gonorrhoea; masturbated moder- 
ately when a boy; was never excessive in venery 
afterward; sexual functions performed normally; did 
not suffer from any signs of vesical irritability. The 
patient's wife was of an exceedingly passionate disposi- 
tion. During the ten months of his married life, with 
the exception of intervals of two or three days, twice a 
month, when he was called out of town, he was re- 
quired to perform the sexual act two or three times 
every night. In the last month he was troubled with 



— 39 — 

frequent urination and some urgency ; with imperfect 
erections; with premature ejaculations; and imme- 
diate subsidence of erection after this. At the same 
time he lost twenty pounds in weight; suffered 
from headache; vertigo; palpitation; some dyspeptic 
symptoms; constipation and a feeling of lassitude. 
He was excessively nervous, so that the slightest 
sound would make him start violently; he had be- 
come petulant, morose, and had his mind almost 
constantly turned on sexual subjects. He was not 
able to concentrate his attention on business matters; 
was restless and exceedingly disturbed over his loss 
of power. After two months of moderation his 
health was completely restored. 

Masturbation may be learned at a very early age. 
I have seen one child, nine months old, who to all 
appearances practised onanism. Children of two or 
three years either learn it themselves or are taught 
the practice by their elders ; sometimes by nurses 
who find that fingering the genitals is an efficient 
method of keeping a baby quiet. It is generally be- 
lieved that masturbation is one of the evils incident to 
school life. Many of the young men whom I have 
questioned on this subject state that they discovered 
themselves the pleasurable sensations which could 
be obtained by friction; sometimes the first stimulus 
was provided by horseback riding, or sliding down 
banisters, or often from handling of the penis in- 
duced by the itching occasioned by a mild balano- 



— 40 — 

posthitis. Once learned, the habit is liable to be con- 
tinued with an instinctive knowledge that conceal- 
ment is necessary, until the boy is clearly made to 
understand that he is doing himself a permanent in- 
jury. Many medical students have stated that not 
until they began their professional reading did they 
learn that the practice in which they indulged was 
injurious. The effect produced varies greatly in in- 
dividual cases. I have seen men who stated that 
from their fifth to the eighteenth year they mastur- 
bated almost constantly — that is, several times a 
week — and yet who experienced no ill effects from it. 
Ordinarily where indulgence is excessive, the general 
symptoms are sufficiently well marked. 

The local symptoms, in the period of boyhood at 
least, excite neither attention nor anxiety. It is com- 
monly taught that the masturbator may be known by 
certain peculiarities. Thus he is given a low, mean 
look, a hang-dog expression; a pallid face; hollow, 
watery eyes; cold, moist hands; lustreless hair; con- 
strained, embarrassed manner; drooping shoulders; 
a tendency toward twitching the muscles; frequent 
repetition of swallowing motions on being addressed; 
weak knees; shrunken sexual organs; a timid, soli, 
tary, irritable disposition ; is supposed to be uncleanly 
in his habits; averse to all society, particularly to 
that of girls; and incapable of intellectual effort. 
This description is no doubt true in certain extreme 
cases, but the absence of any or all of these features 



— 41 — 

will not exclude the fact of this habit being practised, 
and to considerable excess. Some of the frankest, 
manliest and apparently healthiest boys I have seen, 
indulged without stint in this practice, taught their 
comrades with open-hearted generosity, delighted 
in the presence of the opposite sex, and showed in 
their expression and bearing self-respect and inno- 
cent joy in life. 

As a typical instance of aggravated impotence 
directly traceable to masturbation, the following may 
be narrated. 

M. R., aged 26, a mechanic, was always healthy, 
with the exception of convulsions, from which he was 
said to suffer as a child; until his eighteenth year he 
never practised masturbation. He then discovered 
that pleasurable sensations could be produced by 
local friction, and practised onanism several times a 
day for one year. Learning that it was doing him 
an injury, he stopped the practice as far as he was able, 
but was not sufficiently resolved to give it up entire- 
ly. Up to his eighteenth year he had been strong 
and well, had morning erections, and on two occasions 
had been able to perform the sexual act successfully. 
He was small in size, with cold, clammy hands; 
sunken, dark-ringed eyes avoiding the gaze of his 
interlocutor and watering freely; muddy, pimply, 
flabby face; dry, brittle, unkempt hair; scraggy neck, 
with prominent Adam's-apple which rose and fell in 
a distressing manner whenever he was addressed or 



— 42 — 

attempted to speak. His gait was slouching; he was 
uncertain, hesitating and timid in speech, with the 
words imperfectly pronounced, and sentences half 
spoken; and he twisted uneasily while sitting, or 
supported himself while standing up, and nervously 
shuffled his feet. From his incoherent speech I gath- 
ered the history I have given and also the facts that his 
memory was gone; that he was unable to concentrate 
his attention upon any occupation; that he suffered 
from pains in the back, running down along the anter- 
ior and inner surfaces of the leg; that he passed water 
frequently, and often had to hurry; that he had pol- 
lutions once or twice a week. Within the last few 
years he had occasionally feeble morning erections. 
He was tortured with inordinate sexual desires, but on 
the first sexual contact instantly ejaculated, often 
without erection, or even without voluptuous sen- 
sation, and was quite unable to complete the sexual 
act. 

Examination of his sexual organs showed that 
they were not more developed than those of a boy of 
twelve or fourteen years; the penis was two inches 
in circumference, about two inches in length, and the 
testicles were correspondingly small. Beyond this 
there was no apparent abnormality. The meatus was 
small, but on dividing it a 28 sound passed in 
readily, occasioning great anguish when it reached 
the prostatic urethra. The patient was in despair 
over his condition, and was suffering from all the 



— 43 — 

reflex urethral symptoms of which these cases com- 
plain. 

As a result of some weeks treatment, he returned 
greatly improved in general health, and with partial 
restoration of the power of erection. I have every 
reason to believe that this patient during his treat- 
ment steadily continued to masturbate and that his 
ultimate cure was prevented (for I did not succeed 
in curing him beyond the point mentioned) by the 
continuance of this habit. 

Atonic impotence from, prolonged and nngratified 
sexual desire. Those who suffer from this form of 
impotence are by no means the full-blooded pas- 
sionate men, who either from necessity or from 
strength of purpose, are debarred from sexual in- 
dulgence. For instance, sailors who spend months or 
even years in places where woman is unknown, are 
not troubled with sexual weakness when opportunity 
for indulgence is afforded. Nor are the robust men 
of the cities whose minds and bodies are healthfully 
occupied, frequently troubled with this form of im- 
potence. The sufferers from prolonged excitement 
are rather those of a neurotic tendency whose thoughts 
habitually dwell on sexual pleasures, who are given 
to fondling women without violating the written 
law, or to onanism not carried to the point of ejacu- 
lation, whose occupation is neither mentally en- 
grossing nor physically fatiguing. Thus I have most 
frequently seen young farmers troubled with impo- 



— 44 — 

tence from this cause. Commonly it develops into a 
condition of prostatorrhoea, which exceptionally runs 
on to spermatorrhoea, and finally complete paralytic 
impotence with profound deterioration of moral 
fibre. Such a result is rarely produced by an excite- 
ment prolonged through days, or even weeks and 
months. It often takes years to produce appreciable 
effects. The following case is fairly typical of its 
class. 

A. B., a healthy, ruddy, prosperous young farmer 
of twenty-six, since his sixteenth year was much 
given to fondling women. For several years, during 
some part of every day he was subjected to pro- 
nounced sexual excitement. In his twentieth year 
his nocturnal emissions became more frequent than 
before, averaging about once a week. Two years 
later the patient found that the cerebral excitement 
incident to ordinary endearments excited emission. 
These emissions recurred with greater facility, but 
gave him no concern till the time of his marriage, 
when he attempted coitus for the first time in his life. 
Emission took place before intromission, and this dis- 
tressing hypersensitiveness continued in spite of the 
strongest efforts of the will. General hygienic treat- 
ment and a course of posterior instillations resulted 
in complete cure. 

A more serious case is the following : 
A. B., a well-to-do farmer of twenty-two, has al- 
ways been neurotic and somewhat solitary in his hab- 



— 45 — 

its. In his fourteenth year, he masturbated once, 
profiting by the verbal instructions of a friend. For- 
tunately he was detected in the act, and was admon- 
ished by rod and tongue to such purpose that he 
never repeated it. During his childhood and youth 
he brooded almost constantly on sexual subjects; 
sights such as the mating of birds, or the congress of 
animals, threw him into a condition of erotic excite- 
ment which rendered him sleepless at night and unfit 
for his work for days. At such times he would have 
repeated and painful erections, would suffer from tes- 
ticular pains, backache, and nocturnal emissions. 

In his sixteenth year he was thrown much in the 
company of a young woman, with whom the cir- 
cumstances of country life left him alone, and 
whom he caressed on every opportunity, confin- 
ing himself within the limits of decency. As a result 
his previous suffering became augmented, and his 
nocturnal pollutions w r ere more frequent, averaging 
two or three in the week. He finally suffered from 
daily pollutions, at first after more than usually pro- 
longed excitement and as the result of some slight 
mechanical friction. These emissions were excited 
more and more readily till finally they would take 
place before the penis became fully erect and on the 
slightest psychical or physical excitement. In his 
twentieth year he eschewed the company of women, 
but the sexual weakness steadily became more aggra- 
vated. The jolting of a wagon or of a mowing 



— 46 — 

machine would cause feeble erection and emission, 
sometimes repeated two or three times a day. A well 
marked condition of prostatorrhoea was developed, 
and on approaching a female the semen flowed out 
without the slightest sign of erection, and with only 
very feeble pleasurable sensations.. The mental con- 
dition of the patient was deplorable; he had lost 
twenty pounds in weight, suffered from headache, 
giddiness, from palpitation, heart-burn, weak back, 
pains particularly severe in the hypogastric region 
and the right hip, and had become so desperate and 
despondent that he was prepared for any measure 
which would give him relief. He begged to have 
his testicles removed, and indeed was quite deter- 
mined to perform this operation himself if the sur- 
geon refused to perform it. 

Treatment by dividing a narrow meatus, passing 
full-sized sounds, dilating the prostatic urethra once 
up to 40 F., and making instillations of copper sul- 
phate 5 per cent, into the posterior urethra, produced 
such a change in this man's condition that he became 
active in all social affairs of the country side, ceased 
to be troubled by diurnal pollutions, and had noctur- 
nal emissions not more frequently than was normal. 
He experienced vigorous morning erection?, absent 
for more than two years, and regarded himself as 
cured. 

The treatment of impotence dependent upon pro- 
longed and ungratified sexual excitement must be 



— 47 — 

based on the avoidance of all that tends to pro- 
duce such excitement. This end is not always 
accomplished simply by forbidding association with 
women. There is in the majority of these patients 
a mental perversion, a persistent dwelling on sexual 
subjects, which in itself is sufficient to produce local 
congestions. In such cases the patient must be 
urged to use all his strength of will to overcome this 
tendency. He should be advised to seek an occupa- 
tion which will keep him actively employed both 
mentally and physically. If such occupation is 
purely mental it must be supplemented by gymnastic 
exercises. He should be encouraged to spend his 
leisure time in certain lines of study, should be 
directed to exercise vigorously for 15 minutes and 
take a cool sponge bath before retiring, and should 
begin the day with a ten-minute course of calis- 
thenics, followed by a cold plunge bath or shower 
bath. 

This part of the treatment, by far the most impor- 
tant, depends entirely upon the strength of purpose 
exhibited by the patient. To advise such a patient 
to give his passions full swing is, even from a thera- 
peutic standpoint, distinctly objectionable, since he is 
liable to exhibit some weakness in his first essays, 
and, as a result of failure, will have added to his 
original functional deficiency psychical impotence, 
making his ultimate cure much more difficult. 

While the patient is devoting his energies to avoid- 



— 48 — 

ing causes of excitement and diverting his mind from 
sexual subjects, the hypersensitive posterior urethra 
should receive the treatment appropriate to these 
cases; the cold sound, the psychrophor, the prostatic 
dilator, or posterior instillation, being employed in 
accordance with the severity of the local changes 
which have resulted from frequently repeated, long- 
continued congestions. 

Impotence associated with abnormal conditions of 
the urine. It seems reasonable to suppose that the 
hypersesthetic condition of the posterior urethra, 
which is the cause of nearly all cases of atonic impo 
tence, may be occasioned by the irritation incident to 
the passage of urine, which, from the fact that it is 
strongly acid or otherwise abnormal, acts to a greater 
or less extent as an irritant to the mucous membrane. 
It is, however, impossible positively to decide wheth- 
er or not the impotence may notjbe dependent on 
the general causes which induce an abnormal condi- 
tion of the urine, rather than on the direct irritating 
effects of this fluid, since in diabetes, where impotence 
is often absolute, and in Bright's disease, there is not 
necessarily the slightest sign of local hyperemia, nor 
does the introduction of an instrument occasion any 
undue suffering. 

I have, however, repeatedly seen men with oxaluria, 
who suffered from all the local and reflex signs of 
posterior urethritis associated with impotence, and 
whose cure followed hard upon the disappearance of 



— 49 — 

the oxaluria. Again, in the uric acid diathesis impo- 
tence associated with signs of urethral irritation, is not 
infrequently noted, and is usually cured by general 
treatment. The strongly acid urine of acute ephem- 
eral fevers occasionally produces distressing priapism 
from its stimulating effect on the posterior urethra, 
and it is reasonable to suppose that when such irrita- 
tion is long continued atonic impotence will result. 

Under the title Genito-urinary neuroses Ultzmann 
has admirably described the reflex nervous symptoms 
incident to hyperemia, or a chronically inflamed con- 
dition of the prostatic urethra. 

In men the bladder, seminal vesicles and prostate 
are supplied from the vesical plexus, which in turn, is 
made up of anastomosing branches from the hypogas- 
tric plexus of the sympathetic together with filaments 
from the sacral ganglia, and from the pudendal plexus 
of the sacral nerves. This nerve suppl) T explains why 
a constant irritation of the prostatic urethra should 
excite such reflexes as pain passing down the inner 
surfaces of the thighs, or referred to the hips, to the 
anus, to the hypogastric region, or to the small of the 
back. Indeed, all the general and local symptoms 
observed in a hysterical woman, the subject of a 
chronic inflammation of the uterus, are duplicated in 
men, the subjects of chronic catarrh of the prostatic 
urethra," since both the uterus and the prostate are 
richly supplied from the same nerve plexus. 



— 50 — 

The urine, in these cases, is often very abundant, 
and of low specific gravity. Sometimes the polyuria 
is associated with a transient glycosuria. At times 
the urine when secreted is alkaline, dependent not 
upon carbonate of ammonia, but usually upon the 
presence of carbonate of soda. This urine on heat- 
ing becomes turbid from precipitation of the earthy 
phosphates. 

Indican is occasionally observed in the urine of mas- 
turbators, or of those who have indulged in excessive 
venery. A transient albuminuria is also noted at 
times. 

Oxalate of lime frequently appears in great excess; 
also the amorphous and crystalline salts of lime and 
magnesia. Spermatozoa are also found singly in the 
field of the microscope. 

The sensory neuroses of the sexual system may be 
confined to ] sensations like those produced by fluid 
running through the urethra, though there is not the 
slightest sign of discharge, or to neuralgic pains 
referred to the testicles, anus, groins or any of the 
regions innervated by branches communicating with 
the hypogastric and sacral plexus. This hyperesthe- 
sia is sometimes manifested by a sensation of severe 
burning in the region of the meatus after ejaculation. 

Rarely anaesthetic phenomena are observed; the 
penis seems cold and shrivelled; it is sometimes non- 
sensitive to such a degree that the mechanical stimulus 
of coitus is scarcely sufficient to excite ejaculation; 



— 51 — 

even application of the electric brush does not cause 
pain. The urethra shares in this anaesthesia, so that a 
sound may be passed into the bladder without excit- 
ing discomfort. Usually the urethra is markedly 
hyperaesthetic, the passage of an instrument causing 
almost unbearable anguish. 

The motor neuroses of the urinary and genital 
system may appear in the form of over-action or 
paralysis. Thus there is sometimes observed drib- 
bling of urine after micturition from spasmodic con- 
traction of the smooth circular muscles of the urethra. 
Passage of bougies in such cases proves the absence 
of strictures. 

At times there is spasm of the external bladder 
sphincter. In such cases, there is great difficulty in 
starting the act of micturition; the first flow comes 
in drops, or the stream is suddenly interrupted, and 
at the end of the act there is dribbling. At times the 
urine can not be passed, and retention must be re- 
lieved by the administration of anodynes and anti- 
spasmodics, or by the passage of a catheter. 

True cystospasm, that is spasm of the detrusor 
bladder muscles, is much more common than spasm 
of the sphincters. When the detrusor muscles are 
involved, the patient has difficulty in retaining the 
water, is compelled to urinate frequently. Usually 
there is no pain associated with this frequent urin- 
ation. This motor neurosis is a very frequent accom- 
paniment of catarrhal conditions of the prostatic 
urethra. 



— 52 — 

Paresis of the sphincters, or of the detrusor mus- 
cles of the bladder, is exceedingly rare. When the 
sphincters are involved, incontinence results; when the 
detrusors are at fault, the patient suffers from reten- 
tion. 

The motor neuroses of the sexual system may be 
manifested in the forms of priapism, or partial or 
complete impotence, often associated with involun- 
tary seminal emissions and spermatorrhoea. 

Priapism is rarely observed except in the very 
early stages of acute inflammatory involvement of 
the prostatic urethra. Thus in acute posterior ure- 
thritis, in certain cases of prostatic calculus, or 
of growths in that region, there may be repeated 
and prolonged erection, sometimes associated with 
pollutions. 

Impotence is commonly observed as a result of 
chronic inflammation of the posterior urethra. The 
pollutions with which it is associated are due to 
spasm of the detrusors of the seminal vesicles, while 
spermatorrhoea or dribbling of the semen without 
erection or voluptuous sensation is due to paresis 
of the muscular fibres of the ejaculatory ducts. 

The secretory neuroses of the genital system are 
manifested in the form of polyspermia, aspermia 
and prostatorrhcea. 

Polyspermia implies the ejaculation of an abnormal 
quantity of semen; aspermia, the absence of semen; 
prostatorrhcea, a hypersecretion from the prostatic. 



— 53 — 

glands, the glands of Cowper, and the urethral crypts 
and follicles. The great bulk of this hypersecretion 
is contributed by the prostate. 

In addition to these local neuroses, there is com- 
monly in these cases of urethral irritation a pro- 
found constitutional involvement; there is muscular 
weakness, anaemia, dyspepsia, palpitation, asthma, con- 
stipation. There are also psychical changes; the 
patients become timid, morose, solitary, hypochon- 
driacal. The slightest excitement throws them into 
a state of profound agitation. No diversion is suf- 
ficient to lift even for a moment the pall of despond- 
ency which settles over them. I believe that the cause 
of many an unexplained suicide could be found on 
examination of the posterior urethra. 

The diagnosis of atonic impotence. — To determine 
whether or not a given case of impotence is due 
to psychical influences, to organic changes in the 
central nervous system, or to exhaustion of the erec- 
tor and ejaculator centres, the main dependence 
must be placed upon the history of the case. All 
venereal troubles seem to exert more or less of an 
inhibitory influence upon the truth centres, if such 
exist. Hence in every history allowance must be 
made. The physician should, however, be careful 
not to be misled by a skepticism so absolute that the 
improbable is not given close consideration. 

After a careful review of the history, a thorough 



— 54 — 

examination must be made. This will include the 
condition of the circulatory, respiratory and central 
nervous systems. The urine must be examined, and 
in some cases the eye-ground carefully inspected. 
In all cases of impotence a thorough examination of 
the rectum must be made, since reflex impotence 
from fissure, seat-worms or hemorrhoids is by no 
means unknown. Examination of the urine is par- 
ticularly important. Not only must the surgeon 
know the total quantity passed during the day, but 
its specific gravity; its acid, neutral or alkaline 
reaction; the presence or absence of the earthy 
phosphates; of oxalates; of uric acid or excess of 
urates; of indican, sugar and albumen. He must 
carefully search for traces of inflammation in the pros- 
static urethra, and if he finds pus, probably from this 
source, he must discover whether it is due simply to 
the ordinary microbes of suppuration or is associated 
with a still active gonorrhoea! inflammation. 

To determine from which part of the urethra pus is 
secreted, the surgeon should pass a small, soft rubber 
catheter into the urethra as far as the compressor 
urethras muscle, then by means of an irrigating bag 
filled with a mild antiseptic solution, such as 4-per- 
cent, boric acid, the whole anterior urethra should 
be well flushed out. The patient is now directed to 
pass his urine into three perfectly clean glasses. The 
first glass receives the first ounce; the second glass 
receives all but the last half -ounce; the last glass 



— 55 — 

receives the water from the final straining efforts to 
evacuate the bladder. If pus is contained in the first 
glass and the contents of the others is clear, there is 
probably present a moderate catarrhal condition of the 
prostatic urethra, the secretion not being sufficient to 
overfill this part of the tube and flow back into the 
bladder. If all three portions contain pus, there 
is a free discharge which fills the prostatic urethra 
in the intervals of micturition and flows back into 
the bladder. If the first and last alone contain pus, 
there is marked involvement of the prostatic sinuses, 
the contents of which are squeezed out by the last 
act of micturition. Where there is a probability of 
involvement of the bladder in inflammation, the pres- 
ence of pus in the second and third glasses has not 
exactly the same significance. 

Finally comes the examination of the sexual or- 
gans. The condition of the testicles must be noted, 
their size, position, consistency, sensitivenes, and the 
presence or absence of inflammatory swellings, or 
new growths. The development of the penis is 
next considered. It is palpated to discover whether 
indurations are present along the course of the ure- 
thra, or in the cavernous bodies. The prepuce is 
examined as to whether it is redundant or too tight. 
The condition of the lips of the meatus is noted and 
the measurment of the circumference of the penis 
just behind the corona is made. On an average this 
will be from three to three and a half inches. This 



— 56 — 

measurement gives us a*f airly good gauge as to what 
should be the normal calibre of the urethra. The 
urethra of a penis measuring three inches in circum- 
ference should easily take a No. 30 sound. Each one- 
quarter of an inch added to the circumference of the 
penis should indicate a sound two numbers larger. 
Thus a penis three and a quarter inches in circum- 
ference should take a sound No. 32. In cases of impo- 
tence will sometimes be found a penis not more than 
two or two and a half inches in circumference. 
The urethra in these small organs should, however, 
take a No. 26 to 28 sound, since the shrinkage is 
usually in the unstriped muscular fibres of the erectile 
tissue. 

Having determined the normal calibre of the 
urethra, the glans penis is carefully cleansed with a 
mild antiseptic (a pledget of cotton taken from a 
solution of yoVo^ bichloride), and a sterile bulbous 
bougie four sizes smaller than the normal calibre, 



Fig. 9.— Bulbous Bougie. 

should be lubricated with albolene or a mixture made 
up of glycerine, 100 parts; boric acid, 4 parts; car- 
bolic acid, 1 part, and gently introduced into the 
bladder. About six inches from the meatus the in- 
voluntary contraction of the compressor urethra? 
muscle will stop its further passage for a moment. 



— 57 — 

By continued gentle pressure, and particularly by 
directing the patient to make efforts at micturition, 
the spasm will yield and the instrument will pass into 
the bladder, stopping for a moment, perhaps, at the 
internal sphincter, that is, the layer of involuntary 
muscular fibres surrounding the neck of the bladder 
to the inner side of the prostate. The instrument 
should then be slowly withdrawn. During the intro- 
duction and withdrawal of the bougie, the physician 
should note points of resistance to its progress, and 
should look for areas of unusual tenderness. On with- 
drawal, the shoulder of the bulb should be inspected 
for pus, blood or mucus. 

A stricture will be detected either by failure of the 
large bulb to pass in, or by its being resisted for a 
moment and then jumping past the obstacle. On 
withdrawal, the square shoulder of the bulb catches 
in a more pronounced way. Failure to pass the first 
bulb should be followed by efforts to pass successively 
smaller bulbs, unless the resistance be due to the 
spasmodic contraction of the compressor urethrae 
muscle. This is encountered about six inches from the 
meatus; it yields to gentle continued pressure, aided 
by efforts on the part of the patient to urinate, in 
virtue of which the compressor urethrae is relaxed; 
or, if it still resists the bulbous bougie, it can be 
passed readily by means of a full sized steel sound. 
J. William White has shown that on withdrawal of 
the bulbous bougie, the resistance of the posterior 



— 58 — 

layer of the triangular ligament will, in a perfectly 
normal urethra, give the sensation of a slight stricture 
This resistance will be encountered about 6f inches 
from the meatus. Knowledge of this fact will pre- 
vent the surgeon from diagnosing stricture in cases 
where the urethra is normal. 

Personally I have never seen a stricture due to 
onanism, and have seen only one congenital narrow- 
ing of the urethra un associated with other deform- 
ities of the parts. This is, of course, setting aside 
the narrowing which is frequently observed about 
the meatus. 

It may be found that the meatus or the urethra 
just behind it is congenitally so narrow that it will 
not admit a bougie sufficiently large to detect a large 
calibre stricture (over 16 French), even if one is 
present. In such cases there should be no hesitation 
in performing a meatotomy. 

By means of a 10 per cent, solution of cocaine the 
area of operation, although it is exquisitely sensitive, 
may be rendered absolutely anaesthetic. Cocaine is 
applied by means of pledgets of cotton wrapped on 
applicators (an ordinary match stick answers well). 
This pledget is dipped into the cocaine solution, is 
then introduced into the urethra to the depth of 1| 
inches. The cocaine is allowed to remain for three 
minutes, is withdrawn and another pledget inserted. 
The surgeon then enlarges the opening by means of a 
blunt pointed tenotome curved on its convex cutting 



— 59 — 

edge. The incision should be downward and directly 
in the middle line of the fraennm. Under exceptional 
circumstances when the tissues in this direction are 
unusually thin, part of the cutting may be done upon 
the upper surface of the urethra. This cutting should 
be so free that a bulbous bougie two sizes larger than 
the normal calibre of the urethra can be entered and 
withdrawn without meeting with abnormal resistance. 
The patient is then griven a conical meatus bougie and 
a 10 per cent, solution of cocaine. He is instructed to 
cocainize the site of operation immediately before each 
act of micturition: and to insert the meatus bougie 
once a day for two weeks, employing cocaine before 
its introduction, using albolene as a lubricant and 
keeping his instrument as nearly sterile as possible. 

I have seen this operation completely relieve ves- 
ical irritability and partial impotence from which 
the patient suffered for many months. It is pos- 
sible, however, that it acted as much by the mental 
impression it produced, as by any direct beneficial 
effect upon the posterior urethra and indirectly 
the lumbar centres. After division of the meatus, 
either a bulbous bougie four sizes smaller than the 
calibre of the urethra, or a full sized cylindrical 
sound should be introduced into the bladder. A 
cylindrical sound will determine the presence of a 
stricture almost as well as a bulbous bougie; it causes 
less pain than the latter, and allows the surgeon to 
accurately determine the amount of hyperesthesia 
present in the posterior urethra. 



— 60 — 

Examination of the urethra with a urethroscope 
should be employed when there are diseased areas in 
the anterior urethra. The introduction of a straight 
endoscopic tube into the bladder inevitably occasions 
some contusion of the prostatic urethra. The infor- 
mation gathered from inspection of this part is rarely 
more valuable than that obtained by exploring instru- 
ments, which occasion less local injury. The only 
case of epididymitis I have ever had the misfortune 
to occasion by the passage of instruments was due 
to the introduction of a tube of the Leiter urethro- 
scope. 

An examination thus conducted, will show the 
presence or absence of pathological conditions which 
may reflexly produce a hypera?sthetic and finally 
an adynamic condition of the lumbar centres. In 
the vast majority of cases this reflex will start from 
the vesico-prostatic plexus of nerves, a chronic pos- 
terior urethritis being kept up by stricture or by the 
persistence of a gonorrhceal inflammation. 

Although examination of cases of atonic impotence 
usually shows a hyperaesthetic condition of the ure- 
thra, in certain cases, particularly in those associated 
with prostatorrhoea and complete impotence, the whole 
urethra becomes absolutely insensitive, so that the 
passage of an instrument gives rise to no suffering. 
This represents the most advanced and most hopeless 
form of impotence. 

The prognosis of atonic impotence is good, except- 



— 61 — 

ing in the most advanced cases. Frequently, dilata- 
tion of a stricture, and restoration of the urethra to 
its normal calibre, will be found sufficient to produce 
a cure. Generally the hyperemia or inflammation 
of the prostatic urethra must be subdued by direct 
local treatment. 

In the cases suffering from premature ejaculation, 
even though this be associated with imperfect erec- 
tions, the outlook is generally favorable, especially, 
when distinct lesions are found sufficient to cause 
such functional disturbances. In more advanced 
cases, where connection is impossible owing to defi- 
cient or absent erections, if such patients have vo- 
luptuous dreams with erections and emissions, and 
have occasionally vigorous morning erections, the 
outlook is fairly satisfactory, but sometimes a cure 
is extremely difficult to accomplish, since here there 
is a distinct psychical element added to the atonic 
impotence. 

In the paralytic form of the trouble when sexual 
desire is absent, when emissions occur without pleas- 
ure and without erections, the prognosis must be 
extremely guarded, though even in some of these 
cases persistence in rational treatment will bring 
about a cure. 

TREATMENT OF ATONIC IMPOTENCE. 

The treatment of these cases must be both general 
and local. The sleep, diet, exercise and general 



— 62 — 

hygiene of the patient must be carefully regulated. 
While under treatment, sexual relations must be 
strictly interdicted with very few exceptions. The 
patient should be particularly cautioned against 
making an occasional secret trial to discover whether 
or not he is gaining strength. 

Fissure, hemorrhoids or other pathological condi- 
tions about the rectum should receive prompt atten- 
tion. If varicocele is present, it should be cured by 
operation, or an appropriate suspensory bandage 
should be ordered. A redundant prepuce would call 
for circumcision; a narrow meatus for meatotomy. 

All sexual excitement should be avoided with the 
utmost care, and if the thoughts irresistibly run in 
this direction, vigorous exercise and cold bathing 
should be ordered. The urine should be rendered 
bland and unirritating, and when it contains excess of 
phosphates, oxalates, urates, uric acid, etc., appropriate 
dietetic and medicinal treatment must be ordered. 

The local treatment consists in the dilatation of 
strictures; the healing of granular patches of the 
anterior urethra by means of direct applications 
through the endoscope; the curing of hyperaemic and 
inflammatory conditions of the posterior urethra by 
irrigations and instillations, and the passage of full 
sized cold steel sounds, or by the use of the psychro- 
phor. 

The sound (Fig. 1) should be introduced every third 
or fourth day, and should be allowed to remain in for 



— 63 — 

fifteen minutes. In some cases the prostatic urethra 
is so exquisitively sensitive that the introduction of 
the sound occasions a distinct nervous shock. Very 
exceptionally the whole urethra exhibits hyperesthe- 
sia. This may be overcome by first injecting a one 
per cent, solution of cocaine into the anterior urethra. 
An instillator can then be carried down to the mem- 
branous urethra, its tip inserted just within the grasp 
of the compressor urethra? muscle, and ten drops of a 
one per cent, solution of cocaine can be driven into 
the membranous and prostatic urethra. The intro- 
duction of the sound will then be almost painless. 



%^ — * 




Fig. 1.— Steel Sound. 

When there are distinct evidences of a catarrhal con- 
dition of the posterior urethra, irrigation and instil- 
lation will usually be required before a cure is accom- 
plished, though in many cases, particularly those 
dependent on stricture, the use of the sound is suf- 
ficient. 

Irrigation is best practised by means of a small 
(No. 10 F.) soft rubber catheter. This is attached 
to a fountain syringe which contains the lotion to be 
used, is lubricated with antisepticized glycerine, and 



— 64 — 

is passed into the bladder. The stream is then 
started, and the catheter is slowly withdrawn, thus 
flushing out the entire urethra. The solutions which 
give the best results are: nitrate of silver, 1: 6000 to 
10,000; sulpho-carbolate of zinc, 1:1000 to 3000; 
permanganate of potassium, 1:1000 to 3000; per- 
manganate of zinc, 1:3000 to 6000; bichloride of 
mercury, 1:10,000. The efficacy of these lotions is 
increased by administering them as hot as can be 
borne. Such an irrigation should precede the passage 
of the sound, particularly in the cases where examina- 
tion of the urine shows that pus is freely secreted 
from the prostatic urethra. 

After the passage of the sound, instillations should 
be practised. These act directly upon the inflamed 
area, promoting healing, and subduing the hyperes- 
thesia of the terminal nerve filaments of the vesico- 
prostatic plexus. 

Instillations are made by means of a catheter, to 
which is attached a small syringe (Fig. 2). The 
catheter part of the instrument should be cylindrical, 
not conical, it should not be longer than seven 
inches, and its lumen should be very small. A hard 
rubber tube thus constructed with a short terminal 
curve and firmly attached by its shaft to an ordinary 
hypodermic syringe will answer every purpose. 

The medication which is to be employed, is sucked 
up through the tube; the latter is lubricated with 
antisepticized glycerine, and is introduced till its 



— 65 — 

point has just been grasped by the compressor urethras 
muscle. This can be known by the slight, often sud- 
den, sense of yielding, which is felt after a moment's 
steady pressure when the instrument stops at the 
anterior layer of the triangular ligament. The piston 
of the syringe is now driven down, and the instrument 
is withdrawn. 

If the application is made properly, not a single 
drop should escape into the anterior urethra. It is 
important that this should not take place, since solu- 
tions are commonly used for instillation so strong 




Fig. 2.— Instillator. 

that undue inflammatory action would be excited by 
their contact with the anterior urethra. 

The quantity injected each time is ten to twenty 
drops, and the instillations are best made when the 
bladder is neither full nor entirely empty. Of the solu- 
tions employed, nitrate of silver is by all odds the most 
efficient, especially in cases dependent on gonorrhoeal 
inflammation. Sulphate of copper, sulpho-carbolate 
of zinc, iodine and carbolic acid may also be used. 
If nitrate of silver is employed, ten drops of a one 
per cent, solution are first thrown in; the strength of 
the application is increased by one per cent, each 

5 



— . 66 — 

treatment, till it reaches the strength of ten per cent. 
Copper sulphate and zinc sulpho-carbolate are used in 
the same strength. In extremely obstinate cases five 
drops of a mixture of equal parts of iodine and car- 
bolic acid will be found serviceable. If these injec- 
tions occasion local symptoms of excessive inflamma- 
tory reaction, such as pain and continued vesical 
tenesmus, the strength of the application must not 
be increased too rapidly. In many cases it will be 
well not to use solutions of a greater strength than 
five per cent. When the immediate effect of the 
injection is to occasion almost unbearable pain, an 
instillation of cocaine should precede the application 
of the more powerful drug. If a super-sensitive con- 
dition of the anterior urethra is present, this may be 
combatted by means of irrigations of silver nitrate, 
beginning with a solution of the strength of 1 : 6000, 
and running it up to 1 : 3000. 

If in spite of the passage of sounds, tender spots, 
the discharge of blood after instrumentation, and a 
more or less chronic discharge, denote the presence of 
ulcerating spots in the anterior urethra, these should 
be treated by direct applications of a ten per cent, 
solution of nitrate of silver. This can only be accom- 
plished by means of the urethroscope. The Otis 
pattern is the cheapest and the best. 

Heat — Cold. — In some cases the hyperesthesia is 
best combatted by the prolonged application of cold. 
This is accomplished by the psychrophor (Fig. 3). 



— 67 — 

This instrument may be kept at a low temperature 
for as long a time as is desired by means of a stream 
of water constantly flowing through it. The portion 
of the tube passing through the anterior urethra is 
not made cold by the liquid which is allowed to flow 
through, since the latter comes in contact with the 
external walls of the instrument only in its terminal 
three inches. This instrument should be as large as 







A 



Fig. 3.— Psychrophor. 



can be passed into the urethra without undue stretch- 
ing. It is introduced until its curved extremity oc- 
cupies the membranous and prostatic urethra. A cur- 
rent of cold or hot water is then allowed to pass 
slowly through the psychrophor, thus maintaining the 
chamber at its curved end at about the temperature 
of the water. This instrument is used once every 
other day for fifteen to thirty minutes, unless it occa- 
sions grjeat pain, in which case it may be removed 



— 68 — 

sooner, and the intervals between each application 
may be lengthened. 

In cases of atonic impotence characterized by over- 
sensitiveness to the introduction of the sound, and by 
premature ejaculations, but without free pus secretion, 
the passage of cold water through the psychrophor 
is particularly serviceable. In the paralytic cases, 
where the posterior urethra is less sensitive than nor- 
mal, and where erections are feeble or altogether 
lacking, prolonged hot applications will be found 
more efficient. 

The prostatic urethra can also be made to experi- 
ence the beneficial influence of heat or cold, by apply- 
ing these remedial agents through the rectum. Many 
of these cases experience marked benefit from the 




Fig. 4.— Rectal Irrigator. 

use of a rectal douche (Fig. 4) ; cold in hypersesthetic 
cases, or hot where the paralytic stage of the disease 
is pronounced. The rectal douche is best applied by 
means of a two-way injecting pipe, which allows the 
water to flow out as fast as it enters. This douche 
should be employed once a day, a forcible stream 
being turned directly against the prostate. . 



— 69 — 

Another excellent way of applying heat or cold 
through the rectum is by the use of the rectal bag. 
This is constructed very much on the principle of a 
Barnes' bag, or rather the bag employed for elevation 
of the bladder in the supra-pubic operation of cystot- 
omy. It is introduced into the rectum and filled with 
either cold or hot water in accordance with the 
special indications of the case. This may be worn 
for from thirty minutes to two hours at a time, and 
may be daily employed during the early part of the 
treatment. 

When the impotence persists after urethral inflam- 
mation or hyperesthesia has been completely subdued, 
other methods of treatment must be employed to 
restore power to the weakened centres and to the 
muscles concerned in erection and ejaculation. The 
alternate cold and hot needle spray applied to the 
genitalia, the perineum, the hypogastric region, the 
buttocks, the inner surfaces of the thighs, and the 
lumbar spine, acts as a powerful stimulant to the 
lumbar centres. It should be applied once daily, pre- 
ferably in the morning, and should be continued for 
from two to five minutes. 

Wet packs, sitz baths, in fact a complete hydro- 
pathic course will sometimes accomplish a cure, but 
more from improvement in the general health than 
from any special local action. 

Electricity is one of the most powerful means of 
stimulating the fagged lumbar centres. It may be 



— 70 — 

applied in a variety of ways, and we have yet no 
clear knowledge on the basis of which we can predict 
what form of application will be followed by the best 
results in a given case. Either the galvanic or far- 
adic current may be employed. It should first be 
passed the length of the spine, then should be used 
locally. In its local use one pole, the positive, is 
placed over the lumbar spine, the other to the peri- 
neum, the hypogastric region, the anus, or the pros- 
tatic urethra. The electric brush is exceedingly 
valuable; it should be swept over the external genita- 
lia, the hypogastric region, the perineum, buttocks and 
inner surfaces of the thighs, in fact the regions inner- 
vated by the nerves which communicate with the 
hypogastric plexus, and thus with the erection and 
ejaculation centres. 



Fig. 5.— Rectal Electrode. 

The rectal electrode (see Fig. 5) finds its applica- 
tion in those cases of atonic impotence, in which the 
erections are feeble or absent, and the semen dribbles 
out in place of being ejaculated. The sponge of the 
positive pole is in this case placed on the perineum, 
and the entire perineal group of muscles is excited to 
vigorous contraction by means of the electrode intro- 
duced into the rectum. The part these muscles play 



— 71 — 

in erection has been shown already. I prefer the 
slowly interrupted faradic current for use in this 
way. The application should last 15 minutes, and 
should be repeated every other day. 

By the urethral electrode (Fig. 6) the current is 
applied directly to the prostatic urethra and its 
associated muscular fibres. In this case both the far- 
adic and galvanic current may be employed. The 
latter should however never be of such strength as to 
produce a destructive action. 



Fig. 6.— Urethral Electrode. 

Whether it be the psychical effect of electrical 
apparatus and application, or the tonic influence of 
the current, I cannot say; but it remains true, that, 
excepting the results from the direct treatment of 
demonstrable lesions, the percentage of cures of impo- 
tence from the use of electricity is greater than that 
from the use of any other single remedy. 

As an instance of the etfect of electricity the fol- 
lowing case is cited: 

A. B., a man of leisure, aged 43, masturbated but 
once in his life, and that at the age of fifteen. He was 
never excessive in his sexual indulgence, and never 
had venereal disease. He married at the age of 
twenty-five, and begat healthy children. From the 
twenty-fifth to the thirty-fifth year, he practised 
intercourse on an average of once or twice a week. 



— 72 — 

From the thirty-fifth to the fortieth year he was even 
more abstemious, the intervals between intercourse 
being considerably longer, this being necessitated by 
his wife's failing health. In the last year of her life, 
he abstained from intercourse entirely, though pre- 
vious to this time he had experienced no diminu- 
tion in either sexual appetite or power. For a year 
after her death he continued faithful to her memory; 
he was then exposed to temptation and yielded. He 
had what seemed to be a vigorous erection, but ejac- 
ulation occurred even before contact. The erection 
at once subsided. Repeated efforts were followed by 
a like result. The patient shortly drifted into a con- 
dition of the most profound hypochondriasis, com- 
plained of languor, feebleness, headache, vertigo, 
lumbar and hypogastric pains radiating down the 
thighs, constipation, and the general train of symp- 
toms from which such patients suffer. He sank into 
a condition of almost utter despair, meditated suicide, 
and considered all treatment quite futile to help him. 
Examination showed his organs to be healthy; his 
urine normal and his sexual organs without disease. 
His penis was somewhat undersized — 2f inches in 
circumference — but admitted a 28 sound without the 
slightest trouble. The prostatic urethra was unduly 
sensitive. Examination through the rectum showed 
a prostate normal in size. The urine contained no 
pus, and the few shreds found in it were entirely 
made up of mucus. 



— 73 — 

For several weeks the cold sound was passed at 
intervals of three days, and every six days ten drops 
of a one per cent, solution of silver nitrate were 
injected into the prostatic urethra. The diet, sleep, 
exercise and all conditions of life were most carefully 
regulated. In two months he had greatly improved 
in general health, and the erection was entirely nor- 
mal. Directly against the cautions given him, he 
now tried his sexual powers and was shocked 
to find that he was even more impotent than 
before. Erection failed him entirely, though during 
the last two weeks of his treatment he had the morn- 
ing priapism. Strychnia, grain ^V, with phospho- 
rus, grain ^, were administered three times a day; 
hot rectal douches were ordered, two quarts of water 
to be forcibly injected against the prostate once a 
day. In addition he was told to use for three min- 
utes every morning a cold and hot needle spray di- 
rected particularly against the genitalia. Under this 
treatment sexual power was markedly strengthened. 
After six weeks another trial of strength was to him 
at least encouraging, but not satisfactory. He then 
went to a health resort in the mountains and placed 
himself in the hands of a physician, who pursued a 
vigorous tonic and hydropathic treatment, supple- 
mented by injections of spermine. After several 
months he returned to the city but little better than 
when he left. Strychnia and arsenic were now 
administered, 2V of the former and ^ of the latter 



_ 74 — 

three times a day, and the patient was given the 
electric current, galvanic and f aradic, the poles being 
applied to the lumbar spine and to the rectum. Under 
this, his improvement was rapid and marked. He 
believed that the electricity helped him more than 
other measures. After some weeks he was able to 
have connection with almost his pristine vigor, re- 
peating the act several times in a night. He cast off 
all his morbid and melancholy forebodings; picked 
up in weight, became again a cheerful, active mem- 
ber of society, took to himself a wife, and showed, 
by subsequent events, that he was both potent and 
fertile. 



PROSTATORRHOEA. 

The term prostatorrhoea is applied to the inter- 
mittent oozing of the secretion of the prostate gland 
from the urinary meatus. Although this is merely a 
symptom of catarrh of the posterior urethra, it is so 
characteristic of a large class of sexual neurasthenics, 
that it merits detailed consideration. The running 
is greater after micturition and during defecation. 
Some drops of it can be made to flow by digital pres- 
sure on the prostate through the rectum. It is like 
white of egg in appearance, or may be somewhat 
more milky. Microscopic examination shows that it 
is made up of leucocytes, cylindrical epithelium, 
concentric amyloid concretions, and Bottcher's sperm 
crystals. These sperm crystals are quickly formed 
by adding to the discharge a one per cent, solution 
of ammonium phosphate and drying on an object- 
glass. Occasionally blood is found, but this is nearly 
always due to involvement of the seminal vesicles. 

This discharge is nearly always associated with 
marked sexual neurasthenia. It depends for its 
existence upon a chronic catarrh of the prostatic ure- 
thra, including the sinuses, ducts and follicles. The 
examining finger in the rectum usually shows no en- 
largement of the organ; not infrequently, however, 
distinct nodular indurations can be felt in the inflamed 
follicles. 



— 76 — 

The hyper-secretion is constant, but does not flow 
steadily from the meatus, because this is prevented by 
the tonic contraction of the compressor urethrae mus- 
cle. When this muscle is weakened, or when its 
resistance is overcome, as by the passage of hardened 
faeces through the rectum, the discharge will then 
flow forward. 

The patient always regards this discharge as semen, 
and suffers from the psychical effects which reading 
or hearsay has led him to believe are appropriate to 
such a condition. 

Since prostatorrhoea is dependent upon a chronic 
catarrh of the prostatic urethra, its causes can be 
traced to whatever brings about such catarrh. Of 
these, gonorrhoea, masturbation and prolonged and 
ungratified sexual desire undoubtedly are most com- 
mon. Among others occasionally encountered may 
be mentioned acute congestion dependent upon cold; 
direct traumatism; infection as by the passage of a 
dirty sound; the ingestion of certain irritating sub- 
stances, such as turpentine or cantharides, or the 
presence of a diathesis, such as rheumatism, which may 
render the urine irritating. 

In the gonorrhceal cases particularly, the pus cor- 
puscles are fairly abundant. Very few spermatozoa 
are found. If many are present constantly, the con- 
dition is rather one of spermatorrhoea. 

The clinical symptoms of prostatorrhoea are fairly 
characteristic. There is a typical discharge — in sim- 



pie catarrhal cases unaccompanied by pain; in in- 
flammatory cases, that is those approaching in type 
follicular prostatitis, accompanied by pain in the deep 
urethra, with tenderness in the perineum and some- 
times the appearance of blood after urination. 

The persistent discharge is usually associated with 
marked change in temperament and bodily vigor. 

Those unfortunates, the subjects of prostatorrhcea, 
may suffer from any or all of the neuroses discussed 
under the heading of atonic impotence. The local 
symptoms beyond the discharge are commonly limited 
to a sensation of liquid trickling along the canal; 
tickling sensations far back; frequent urination and 
some urgency in performing the act; reflex pains and 
aches in the rectum, the hypogastrium, the small of 
the back, and down the inner surface of both thighs. 
All these pains are greatly aggravated by prolonged 
standing, and are usually associated with a distinct 
lessening of sexual power, so that emissions are pre- 
mature, erections are feeble, or even may be quite 
wanting at the critical time. In some cases, beyond 
the prostatic discharge, there are no symptoms. 

A fairly typical history of a case of prostatorrhcea 
is as follows: 

A. B., aged 18, student, was always healthy, and 
had a good family history; never had venereal dis- 
ease and was chaste in his conduct with the opposite 
sex. From the thirteenth to the sixteenth year he 
masturbated. He then stopped entirely. For one 



— 78 — 

year he has been much worried about the condition 
of his penis. He thinks it is too small; feels running 
sensations through it at times; has not the power of 
forcibly expressing the last few drops of urine, so 
that there is some dribbling, and has nocturnal pollu- 
tions about twice a month. He states that for some 
months there has been, after the end of each urina- 
tion a sticky, transparent drop, which hangs to the 
meatus. This drop also appears after straining at 
stools. He suffers from occasional pains in the back, 
over the hypogastrium and down the inner surface of 
the thighs. He passes water four times a day, and 
rises once in the early morning to do this. Sometimes 
he passes it more frequently, and suffers from 
urgency. Before the beginning of his local troubles 
he was exposed to prolonged, ungratified sexual 
excitement. 

The patient has not had normal erections lately, 
but experienced normal desires for women, and on 
appropriate stimulation had violen f [erection. He 
complains of loss of memory, dull, heavy feelings 
and a constant sense of fatigue. His mental suffer- 
ing was accentuated by the fact, that he fancied the 
flaccid penis should be about as movable in the nor- 
mal person, as is the tail in the dog, and that he was 
suffering from paralysis. 

Examination of the urethra showed the absence of 
stricture, but an excessively sensitive posterior ure- 
thra. Rectal examination showed a prostate normal 



— 79 — 

in size and slightly lobulated. Pressure upon the 
gland caused several drops of prostatic fluid to flow 
from the meatus. Microscopic examination of this 
showed the typical discharge containing the concen- 
tric amyloid bodies, without admixture either of pus 
or spermatozoa. 

After some weeks treatment by means of the cold 
sound and instillations of weak solutions of nitrate 
of silver, this patient entirely recovered. He no 
longer had discharge of any fluid, was able to ride 
horseback without experiencing any return of his 
trouble, and appeared quite normal in every way, re- 
suming his work with what was to him new vigor. 

The prognosis of prostatorrhtea is as a rule very 
good. The cases which present themselves are 
usually derived from three classes: 

1. Those suffering from the remains of an uncured 
gonorrhoea. These represent mostly city men of 
loose morals; 

2. Men who have been the subjects of prolonged 
ungratified sexual desire. These usually represent 
countrymen, who, from reasons founded on morality 
or from fear, resist, but do not flee temptation; 

3. Half-grown or grown boys, who have been given 
to inordinate masturbation, to lascivious reading and 
to long brooding on sexual subjects. These are 
drawn from either the city or country, are usually 
of medium intelligence, often have in them germs of 
disease such as tuberculosis, hereditary syphilis, etc. 



— 80 — 

Patients belonging to the first two classes are cured 
with but few exceptions, provided they can spare the 
time necessary for treatment, and exert the self-con- 
trol required by strict observance of the orders given 
them. 

Patients of the third class, though younger in 
years, and hence a priori easier to cure, often do not 
yield to treatment. This is probably because their 
habit has such a hold upon them, that they cannot 
overcome it, and because, being usually of weak con- 
stitution, their recuperative power is slight. I am 
certain that I have seen some of these cases distinctly 
aggravated by vigorous treatment; each application 
or mechanical interference acting as a shock to the 
enfeebled constitution, from which reaction was slow 
and imperfect. 

Treatment. — Since the underlying lesion in these 
cases is catarrh of the mucous membrane of the pros- 
tatic urethra, this catarrh extending into the ducts 
and glands, the treatment of prime importance is 
that directed to the subduing of such catarrh. 

Several times I have seen a prostatorrhcea of long 
standing cured, by the observance of general hygie- 
nic rules, and the ingestion of food and medicine cal- 
culated to correct an abnormal condition of the urine. 

The bowels must be opened regularly; fluid extract 
of cascara, or better than this a teaspoonful of sul- 
phate of magnesia in a quarter of a glass of water, or 
a claret glass of hunyadi on rising in the morning, 
will be found serviceable. 



— 81 — 

The bathing must be regulated. Where the patients 
are vigorous and cold water suits them, showers or a 
plunge in the morning maybe recommended. If the 
patients are feeble, a hot plunge bath is advisable. 

Exercise must be prescribed. In some cases bi- 
cycle riding or horseback exercise distinctly aggra- 
vates the condition. This is particularly the case, 
when there is a low grade of follicular prostatitis; that 
is, when in addition to the catarrhal process the paren- 
chyma of the gland is more or less involved. In other 
cases such exercise is particularly serviceable, produc- 
ing on the prostate the effect of massage, increasing 
the tonicity of its blood vessels and materially les- 
sening the quantity of discharge. 

Stimulants must be tabooed except at meals, and 
then they should be taken in moderation. 

The clothing must be regulated in accordance with 
the weather, and the feet must be protected from the 
damp, since chilling of the surface exerts a particu- 
larly bad effect upon inflammations about the neck of 
the bladder. 

Medical treatment, though of minor importance, 
should not be neglected. Among the most useful 
drugs are those which in their elimination stimulate 
the prostatic mucous membrane. Oil of sandalwood 
has seemed to me more valuable in its effects than 
all the other remedies of this class. It may be given 
encapsulated, in ten-minim doses three times a day, 
one hour after each meal. Cubebs, copaiba, turpen- 



— 82 — 

tine, cantharides in small doses, all have been highly- 
recommended; belladonna is serviceable where there 
is irritability of the bladder; indeed it and its alka- 
loid atropia are held in high esteem by those most 
experienced in this class of cases. Bromide of potas- 
sium frequently is most useful, particularly where 
there is intense hyperesthesia, and where general 
neurasthenia is well marked. As general tonics the 
compound syrup of the hypophosphites in teaspoon- 
ful doses, cod-liver oil with iodide of iron, and 
iron and nux vomica in combination are to be recom- 
mended. 

The local treatment is the one on which main 
dependence must be placed. This is designed to 
cure catarrh and to allay hyperesthesia. The various 
methods of treatment have been already described 
under Atonic Impotence. 

The use of soluble prostatic bougies has not given 
me as satisfactory results as have instillations. If 
bougies are employed, the more strongly astringent 
ones are to be preferred. Each bougie may con- 
tain some such prescription as this: Zinc sulphate, 
grains ii; carbolic acid, grains ii; fluid extract of hy- 
drastis, m xv. These bougies are introduced by 
means of a special carrier, and are perhaps most use- 
ful, when the patient is himself compelled to continue 
his treatment. 

Occasionally the prostatic dilator (Fig. 7) will be of 
service. It has seemed to me to accomplish its good 



83 



effect by mechanically emptying the 
diseased follicles of their contents, and 
thus allowing the instillation, which 
should always follow the dilatation, to 
gain access to every part of the mucous 
membrane. This is a means of treat- 
ment which should not be repeated 
more than once in ten days, and which 
should be practised with caution. 
Stretching should not be less than 36 
of the French scale, nor more than 44. 
Full dilatation of the prostatic urethra 
by means of the steel sound is impossi- 
ble, since an instrument sufficiently 
large to overstretch the membranous 
urethra, fits loosely in the physiologi- 
cally wider prostatic portion of the tube. 
Gross and others hold that flying blis- 
ters to the perineum are extremely valu- 
able. Personally I have never seen 
marked beneficial effects follow their 
use. They often occasion considerable 
inconvenience or even actual suffering- 
Electricity is often of service. The 
proper current for any individual case 
cannot be formulated. The galvanic 
current, one pole applied to the lum- 
bar spine, the other to the prostatic 
urethra by means of a properly ar- 





— 84 — 

ranged urethral electrode, is perhaps most popular. 
I have, however, in some cases, particularly in those 
where coincident with prostatorrhoea there was a very 
marked failure of sexual power, seen much more rapid 
effects from the farad ic current. 

In nearly all cases sexual intercourse must be 
interdicted. When the disease occurs as the result 
of over-indulgence upon the part of married men, 
after a brief period of abstinence moderate inter- 
course may be allowed, since total prohibition may 
keep the patient in a condition of prolonged and 
ungratified sexual excitement. This, however, must 
be determined by the effect produced by intercourse. 
If this aggravates the discharge, and particularly if 
it is followed by lassitude and lumbar pains, it must 
be forbidden absolutely. 

In the majority of cases recovery will follow in 
from one to three months; sometimes a much longer 
period is required. 

In some cases local treatment appears to be dis- 
tinctly aggravating. Here it is advisable, if the 
patient's circumstances are such as to allow it, to 
make a complete change in the mode of life. A pro- 
longed vacation spent in travel or in camping out, or 
on a shooting expedition will sometimes cure a case 
which has obstinately resisted local and general treat- 
ment. 



INVOLUNTARY SEMINAL EMISSIONS. 

Involuntary seminal emissions, though properly 
classed with the symptoms of atonic impotence, as- 
sume such an importnce in the eyes of patients, and 
appear in such varying clinical forms that they require 
detailed consideration. 

Cases suffering from seminal emissions will com- 
plain of symptoms corresponding to the following 
classification: 

1. Nocturnal pollution, the result of lascivious 
dreams, or a local hyperesthesia so marked, that 
stimuli too feeble to produce any effect in health are 
sufficient to excite ejaculation of semen. Usually at- 
tended with vigorous erection and voluptuous sensa- 
tion. 

2. Diurnal pollution, the result of impure thoughts 
or of a peripheral irritation too feeble to excite emis- 
sion in a healthy man. Usually attended with feeble 
erection or at least one which quickly subsides, and 
with blunted voluptuous sensation. 

3. Spermatorrhoea, a condition in which the semen 
oozes from the meatus without erection, and without 
pleasurable sensation. This loss may be due to im- 
pure thoughts, or may occur quite independently of 
appreciable psychical or physical stimulus. The dis- 
charge flowing as in prostatorrhoea after micturition 
and during defecation. 

Nocturnal pollution. — An occasional emission dur- 
ing sleep, once every two weeks for instance, is, in a 



— 86 — 

continent men, no sign of undue irritability of the 
sexual organs. Indeed it is rather to be desired, since 
it disposes of an accumulated secretion the presence 
of which is liable to excite disturbing reflexes. In 
healthy young men who lead idle lives and who are 
subjected to venereal excitement, these pollutions may 
occur much more frequently, two or three times a 
week, and yet indicate no abnormal local condition. 
It is not uncommon to find healthy men who have no 
pollution for many weeks; yet after prolonged physi- 
cal exertion such as is required in an all-day hunt, or 
a long walk, or without apparent cause, they may 
have several emissions in a single night. Those who 
work hard, who sleep and eat sparingly, and who are 
not exposed to sexual excitement, may be continent 
for months or years without a single emission. 

Nocturnal pollutions can only be considered as in- 
dications of seminal weakness when they are unduly 
frequent, are followed by lassitude and mental de- 
pression, and particularly when they are associated 
with partial or complete impotence. 

If such emissions persistently occur three or four 
times a week, when the surroundings of the patient 
are such that he is not exposed to prolonged sexual 
excitement, and if there is a lessening of physical 
strength, a sense of fatigue, a disinclination for mental 
effort, it is quite certain that there is an asthenic con- 
dition of the ejaculation centre brought about reflex- 
ly or dependent upon systemic causes. 



— 87 — 

These unduly frequent nocturnal pollutions are 
often associated with full sexual vigor. If uncor- 
rected, however, the erethism of the ejaculatory 
centre becomes more marked, and there is developed 
a more or less pronounced form of sexual weakness. 

Diurnal pollutions, or ejaculations as a result of 
slight psychical or local stimulation, may occur from 
embracing a woman or even being in the same room 
with her, from friction of the garments incident to 
horse-back riding, from the titillation of a shower 
bath. Indeed, any slight irritation applied to the 
penis, maybe sufficient to excite immediate ejaculation. 
I saw one man in whom the act of retracting the pre- 
puce for the purpose of cleanliness invariably excited 
ejaculation; the passage of a meatus bougie caused 
the same result. In another case a digital examina- 
tion of enlarged inguinal glands was sufficient to 
excite an erection and ejaculation. The reading of 
lascivious literature, the hearing of lewd stories, or 
the simple imaginings of sexual relations are sufficient 
to excite an orgasm. The erections when this con- 
dition of erethism is developed, are usually feeble, 
exceptionally they are vigorous, but subside promptly 
when emission has taken place. 

Spermatorrhoea. — The erection and emission cen- 
tres, though distinct from each other, are so closely 
related physiologically, that erethism and adynamia of 
one imply a like condition of the other; hence in the 
most aggravated form of sexual weakness, the semen 



— 88 — 

is discharged without pleasurable sensation and with- 
out erection, oozing from the urethra, instead of being 
ejaculated by rhythmic muscular contraction. This 
oozing may occur as a result of sexual excitement or 
local irritation. The sight of a woman may cause it, 
or it may be due to the jolting of a wagon or to in- 
tentional friction. The following case sent me from 
the country well illustrates this phase of seminal 
weakness. 

A. B., aet. 26, masturbated furiously when sixteen 
years of age; this he continued for one year, then 
stopped entirely. Following his excess in this direc- 
tion, he was troubled with frequent nocturnal pollu- 
tions, three or four a week. This continued for some 
years, when he began to notice that attempts at in- 
tercourse were not satisfactory, erection was imper- 
fect and ejaculation premature. In the last year 
seeing or touching a lewd woman at once excited an 
emission, unattended with pleasurable sensations and 
without erection. There was no discharge from the 
penis after urination or defecation, no stricture, 
nothing abnormal except a very small penis. He 
stated that his morning erections were vigorous. 
This last statement in regard to the morning erection, 
if true, offers an exception to the general rule, for as 
such cases belong to the paralytic type, the erection 
centre and the muscles innervated by it, and the 
plexuses anastomosing with it, are too much exhaust- 
ed to react fully to the irritation of a full bladder. 



— 89 — 

This patient under rectal douches, bougies, pos- 
terior instillations and tonic treatment, recovered 
sufficiently to break through the strict order in regard 
to chastity and fornicate repeatedly. This act he 
was able to accomplish, but from constant trials of his 
strength did not regain full power, and finally dis- 
appeared. 

Spermatorrhoea, in the sense of a constant flow of 
semen from the urethra after urination, during defe- 
cation, and at odd times, spermatozoa also being found 
in the urine, is very rare. Exceptionally a vigorous 
man, who has been given to masturbation, or exces- 
sive fornication, and who stops suddenly, will, in 
place of frequent nocturnal pollutions, be troubled 
with mucous discharge, which on examination will be 
found to contain many spermatozoa; this represents 
an overflow from the seminal vesicles due, no doubt, 
to temporary paresis of the muscular fibres of their 
ejaculatory ducts. It is, however, not associated with 
loss of virile power, and though observed in those 
who exhibit a mild degree of sexual hypochondriasis, 
it is a condition which under appropriate treatment 
promptly subsides. I have seen but one case of true 
spermatorrhoea. This was as follows: 

A. B., clerk, aged thirty -tw 7 o, addicted to mastur- 
bation for twelve years; has never had connection 
with a woman and feels for women no natural desires. 
During the last two years he has had a constant 
running from the penis, aggravated on urination and 



— 90 — 

defecation. He has frequent nocturnal pollutions; 
these do not wake him, and he is only aware of them 
from finding the stains on his garments. During 
defecation (especially if he is slightly constipated) the 
discharge is pronounced, has a seminal odor, and 
slightly pleasurable sensations are experienced during 
its flow. This discharge runs from the penis in drops 
without erection. Four years ago the patient noticed 
that morning erections were absent and priapism did 
not result from libidinous thoughts. Later, in the last 
two years, libidinous thoughts caused running of 
sperm-like fluid from the penis without marked pleas- 
urable sensations. For the last year he has had no 
erection. Friction of the glands produced discharge 
of a whitish fluid. 

The patient was in appearance a typical m.astur 
bator. He was small, emaciated, hollow-chested 
thin-necked, weak-kneed, shambling in his gait, 
careless in his dress and person. In his deep-set 
eyes rested the shadow of despair. His pale, hollow 
cheeks, and general expression of moral abasement, 
were sufficiently indicative of the practice which had 
brought him to his condition. His penis and testi- 
cles were unusually small. The penis was cold, 
shriveled and almost cartilaginous in its density. 
Examination of his urine showed large quantities of 
spermatozoa and oxalates in abundance. The fluid 
discharged during stool and after urination was 
swarming with spermatozoa. He complained of all 



— 91 — 

the various reflexes with which these patients are 
afflicted, headache, loss of memory, tinnitus aurium, 
bad taste in the mouth, wind on the stomach, obsti- 
nate constipation, palpitation of the heart, shortness 
of breath, colicky pains, backache, uncontrollable 
restlessness, pains in the hypogastrium running down 
the thighs, burning in the anus, etc. Application of 
the porte caustique to his prostatic urethra stopped his 
discharge. 

He was lost sight of, however, before any return 
of sexual power was noted. 

The causes of involuntary seminal emissions are the 
same as those which excite catarrh of the posterior 
urethra and prostatorrhoea. The lesion produced is in 
the first place hyperemia or inflammation of the 
prostatic urethra. This leads to hypersensitiveness 
of the erectile and ejaculatory centres, followed by 
adynama, or exhaustion. Of the most frequent causes 
may be mentioned prolonged and ungratified sexual 
excitement, masturbation and sexual excess, gonor- 
rhoea! inflammation, exhaustion from overwork, anx- 
iety or grief; or from constitutional conditions, such 
as acute fevers or consumption in its early stages; 
organic lesions of the central nervous system, such as 
are observed in bulbar paralysis; the abuse of drugs, 
such as alcohol and opium; reflex irritation from the 
penis, such as that due to phimosis or herpes of the 
prepuce, or narrow meatus; reflexes from the anus and 
rectum, such as are dependent on fissures, piles, 



— 92 — 

polypi, or irritation incident to worms or to skin 
eruptions or obstinate constipation. 

The diagnosis of spermatorrhoea must be founded 
on microscopic examination. If the sperm-like dis- 
charge, which flows during defecation, after urination 
and at other times, on repeated examination is found to 
contain a few spermatozoa, never in great numbers, it 
may be concluded that the case is one of prostatorrhcea. 
If, however, spermatozoa are very numerous in this 
discharge, and are nearly always found, the case is one 
of spermatorrhoea. However, the differential diagnosis 
is not very important, since the treatment of the 
aggravated forms of both affections is much the 
same. 

The prognosis in these cases is fairly good, when 
there is no organic lesion of the central nervous sys- 
tem, and when the patient still possesses determina- 
tion enough to help the physician. Some cases im- 
prove rapidly under very simple treatment, particu- 
larly that directed to subduing the hypersensitive- 
ness of the prostatic urethra. Others, however, 
yield not at all. In these cases it is possible that 
the centres are permanently injured or that changes 
have taken place in the secreting and excreting ap- 
paratus too gross to be repaired. 

The treatment of nocturnal pollutions must be 
partly psychical. The great majority of patients 
consulting physicians in regard to this condition, 
have in reality emissions no oftener than are consis- 



tent with perfect health. From reading misleading 
literature, however, the patient fancies that the loss 
is producing a disastrous drain on his system, and is 
apt-to suffer from symptoms which he judges would 
be commensurate with this loss. The physiology of 
such pollutions should be clearly explained; the life 
should be regulated according to hygienic principles; 
the patient should be cautioned against thoughts of a 
libidinous nature, against everything which is liable 
to cause sexual excitement. He should have his 
bowels opened at night before retiring, either by cold 
enema, or by means of salts taken during the day, until 
the habit of evacuation at this time is acquired. He 
should sleep on a rather hard bed, lightly covered. 
He should avoid sleeping on his back, and this may be 
managed by securing a band about the waist con- 
taining a block so placed that it presses on the spine 
when the patient assumes the dorsal decubitus; thus 
sleep is disturbed. Furthermore the patient should 
train himself to wake once during the night and 
empty his bladder, and before retiring practise light 
calisthenic exercises and take a cold or cool sponge 
bath. 

When, in spite of these precautions, erections and 
emissions occur, the patient should adjust a ring to 
the penis, so arranged, that when this organ becomes 
congested, the sharp teeth with which the outer band 
is set around press upon the skin and disturb sleep. 
(See Fig. 8.) 



— 94 — 

All sources of reflex irritation must be carefully 
sought for and removed; thus the rectum should be 
examined for fissure and hemorrhoids. The possi- 
bility of ascarides must be considered. In cases of 
phimosis, circumcision should be performed. Narrow- 
ings of the meatus must be cut; strictures further 
back must be divided or dilated; hyperesthesia or 
hyperemia of the prostatic urethra must receive the 
treatment described in discussing atonic impotence. 
Varicocele or hydrocele, if present, should be cured. 




Fig. 8.— Pollution Ring. 

Though the local treatment is perhaps of prime 
importance, general treatment must not be neglected. 
When the nocturnal pollutions are very frequent, 
bromide should be administered in full doses, 30 to 90 
grains at bed-time. Bartholow particularly recom- 
mends the mixture of this drug with the fluid extract 
of gelsemium in 10-drop doses. Atropine, grain -g-i-g-, 
three times daily with twice this quantity given at 
bed-time; hyoscine, grain -g-^-g- to grain r | T at night; 
lupulin, grains xx, three times a day; monobromate 
of camphor, warmly commended by Hare, 5 grains 



— 95 — 

in pill form three times a day; antipyrin, grains xv, 
three times a day. Each of these drugs may, in in- 
dividual cases, serve as a powerful auxiliary in accom- 
plishing a cure. 

In the cases which have progressed to the point of 
diurnal pollutions, local treatment is of special im- 
portance. In addition to the posterior instillations, 
and the solid stick of silver nitrate applied by the 



x . 'Jim an. '^zzzrrrrr-^zzzzi 




JCJlBWT.V'=:s=._ 




Fig. 10.— Porte Caustique. 



porte caustique (Fig. 10), the patient should receive 
hot rectal douche^, the hot and cold needle spray to 
the external genitalia, perineum and lumbar region, 
and the galvanic and f aradic current over the lumbar 
spine, in the rectum, and in the prostatic urethra. 

The first effect of electricity is to aggravate symp- 
toms; shortly improvement sets in, and is generally 
marked. 

Of the drugs to be employed in the paralytic form 
of seminal incontinence, those should be chosen, 
which tend to restore tone to the weakened muscles, 
and to revitalize the exhausted lumbar centres. 
Among the drugs which have been found most effica- 
cious are the following; the dose named is that 



— 96 — 

appropriate to each administration, when the medi- 
cine is ordered to be taken three times a day: Strych- 
nia, grain 2V alone or in combination as found in 
the compound syrup of the hypophosphites a tea- 
spoonful; fluid extract of ergot a teaspoonful; arsen- 
ious acid, grain ttj to grain *V; extract of damiana, 
grains iii to grains v a day; phosphorus, grain jws. 



IMPOTENCE OF THE FEMALE. 

If we adopt the same classification as was observed 
in discussing impotence and sexual weakness in the 
male, this affection, as observed in the female, 
must be limited to cases of malformation either 
hereditary or acquired, to obstruction from new 
growths and to muscular spasm, since in the case of a 
woman performance of the sexual act, at least in so- 
far as her partner is concerned, requires only the 
presence of a sufficiently long and patulous mucous 
canal. 

From the standpoint of the woman, however, fail- 
ure to experience an orgasm, after what may be 
regarded as sufficient mechanical stimulus, represents 
a common form of impotence. 

Impotence in the female may be classified under 
the following heads: 

1. Intromission of the male organ is impossible. 

2. Intromission is possible, but causes extreme 
pain. 

3. Intromission is possible, and does not occasion 
pain, but the mechanical and psychical stimulus is not 
sufficient to excite orgasm. 

1. Intromission of the male organ may be impos- 
sible, because of obstructive pathological conditions 
of the vulva and vagina; these may be congenital or 
acquired. 

The congenital anomalies may take the form of 



— 98 — 

absence of the vagina; extreme narrowing of this 
tube, or its division into two parts, each too small 
to allow of intromission; or the vagina may have its 
outlet in an abnormal position; thus it sometimes be- 
comes continuous with the rectum. 

On the part of the vulva there may be adhesions of 
the greater or smaller lips; there may be hypertrophy 
of the labia? or clitoris, or, what is perhaps the most 
frequent congenital cause of obstruction to sexual 
relations, there may be a rigid or imperforate hymen. 

Barring the absence of the vulva and vagina and 
the presence of an imperforate hymen, nearly all of 
these conditions may be brought about by injury or 
disease. Thus extreme atresia may result from acute 
inflammation; elephantiasis may cause such swelling 
of the labia? that sexual approach is impossible; gan- 
grene, or extensive ulceration, may practically close 
the vulva. Deformity, the result of disease, such as 
coxalgia or spinal disease may render approach almost 
impossible. 

Treatment of impotence, when it depends upon 
congenital absence of the vulva or vagina is, of course, 
of little avail. In cases of narrowing, continued dila- 
tation may bring about a cure. In at least one case 
where the vagina opened into the rectum, the woman 
became pregnant. 

Rigid or imperforate hymen, adherence of the 
labise, mechanical obstruction offered by tumors can 
of course be relieved only by surgical operation. 



— 99 — 

2. In women with whom intromission is possible but 
who suffer such pain that all voluptuous sensations 
are abolished, there may be some demonstrable path- 
ological condition such as inflammation or malposi- 
tion, or the most careful search may fail to find the 
slightest sign of abnormality beyond intense hyper- 
esthesia. 

All acute inflammation about the vulva, vagina, 
rectum, uterus or ovaries may render sexual approach 
painful. Urethral caruncles and urethritis, fissures at 
the neck of the bladder, hemorrhoids or rectal fissures, 
ulcerations or displacement of the womb, inflamma- 
tion of the fallopian tubes, disease or prolapse of the 
ovaries, are frequently observed as causes of this con- 
dition. At least, when such lesions are cured by ap- 
propriate treatment, the pain attendant on sexual rela- 
tion disappears and normal voluptuous sensations are 
experienced. 

As a consequence of the pain excited by efforts at 
intromission, there sometimes occurs an involuntary 
tetanic spasm of the perineal muscles, termed vagin- 
ismus. This renders the sexual act extremely diffi- 
cult, and sometimes makes it quite impossible, even 
though the male possess a vigorous erection and bru- 
tal insistence. It is observed particularly in hysterical 
females. Not only the sphincter vagina? and transverse 
perinei, but the sphincter and levator ani and also the 
involuntary muscles of the vagina are involved. As a 
result the orifice and vaginal canal tightly close, and 



— 100 — 

any attempt to overcome the muscular resistance 
occasions intolerable pain. 

Occasionally this condition comes on after intro- 
mission is effected. In such cases it is quite possible 
for the male organ to be so tightly imprisoned that 
release is not accomplished until ether is administered 
to the female. Several such cases are reported in lit- 
erature, and one recently occurred under the care of a 
medical friend. 

Though this condition is usually classed among the 
pure neuroses, there is usually some source of irrita- 
tion, which if treated relieves the condition. Rarely, 
hyperesthesia of the vaginal mucous membrane seems 
to be the sole cause of spasm. 

The treatment of these cases depends for its suc- 
cessful issue upon the cure of the abnormal conditions 
which give rise to pain and excite reflexes. A most 
careful examination of the entire genito-urinary tract 
must be made. Lesions or displacements of appar- 
ently slight moment must receive treatment. The 
usual cause of this condition is inflammation, often 
Assures at the neck of the bladder. The rectum must 
be explored with the speculum, and ulceration, fissures, 
or varicose veins must receive surgical attention. If 
the vaginal introitus is unduly narrow it may be over- 
stretched under ether. A partially ruptured hymen 
must be divided. Finally if no lesions are discovered 
and if the vaginal mucous membrane is hypersesthetic, 
before sexual approach a ten per cent, solution of 



— 101 — 

cocaine should be applied to this canal and its outlet 
by means of cotten swabs, and the whole mucous 
surface should be douched daily with hot boric acid 
solution two quarts, and should be touched once a 
week with a four per cent, solntion of silver nitrate. 

3. Even though intromission is possible and painless, 
it is often the case that no orgasm is experienced by the 
woman. It is undoubtedly true that women, as a rule, 
are less passionate than men, that many wives and 
mothers have never experienced an orgasm, that the 
sexual act is for them merely an expression of conjugal 
obedience or a means of bearing children, that in 
itself the whole process is unpleasant or even posi- 
tively revolting. This depends, not so much upon 
local conditions, as upon a frigidity mainly inborn, 
but partly the result of education. 

Many women occasionally experience an orgasm, 
but usually stop short of this, since their husbands 
are unable to continue the act for a sufficient length 
of time. This is sometimes the fault of the man, but 
more frequently is due to the slow response on the 
part of the woman. 

In cases such as these local treatment is of little 
avail ; the impotence can be classed as psychical, and 
as such must be treated by means of mental impres- 
sions. Liquor in moderation, rich food, sea air, and 
caresses may awaken some response, but at most a 
feeble one. Since sexual desire is dead, pleasure in 
the sexual act is not to be excited; nor is this to be 



— 102 — 

regretted, since such women make good wives, loving 
mothers, and are not tempted to stray in the paths 
which the comparatively small number of their more 
amorous sisters at times find too alluring. 

When an orgasm is experienced only at rare inter- 
vals, because of a too hasty partner, the remedy lies in 
allowing longer intervals to elapse between each 
approach, in making such approaches gradual, and 
in an effort of the will on the part of the male, by 
means of which ejaculation may be postponed. The 
effect of continued efforts in this direction is truly 
wonderful. I have seen men who stated that they 
could postpone ejaculation for one or two hours, and 
there is a religious sect in the state of New York 
who train their youth so that the intercourse may be 
continued for many hours without ejaculation. 



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as a Restorative of the Circulation in Enfeebled Heart; and 
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Tonic and Stimulant. 



Full information concerning our products afforded on 
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express charges. 



PARKE, DAVIS & CO., 

Detroit, New York, Kansas City, and Walkerville, Ont. 



BUEEETIN "'PUBLICATION^ 



OF 



GEORGE S. DAYIS, Publisher. 



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SERIES I. 



Inhalers, Inhalations and Inhalants. 

By Beverley Robinson, M. D. 
The Use of Electricity in the Removal of 
Superfluous Hair and the Treatment of 
Various Facial Blemishes. 

By Geo. Henry Fox, M. D. 
New Medications, Vol. I. 

By Dujardin-Beaumetz, M. D. 
New Medications, Vol. II. 

By Dujardin-Beaumetz, M. D. 
The Modern Treatment of Ear Diseases. 

By Samuel Sexton, M. D. 
The Modern Treatment of Eczema. 

By Henry G. Piffard, M. D. 



Antiseptic Midwifery. 

By Henry J. Garrigues, M. D. 
On the Determination of the Necessity for 
Wearing Glasses. 

By D. B. St. John Roosa, M. D. 
The Physiological, Pathological and Ther- 
apeutic Effects of Compressed Air. 

By Andrew H. Smith, M. D. 
GranularLidsandContagiousOphthalmia. 

By W. F. Mittendorf, M.D. 
Practical Bacteriology. 

By Thomas E. Satterthwaite, M. D. 
Pregnancy, Parturition, the Puerperal 
State, and their Complications. 

By Paul F. Munde, M. D. 



SERIES II. 



The Diagnosis and Treatment of Haem- 
orrhoids. 

By Chas. B. Kelsey, M. D. 
Diseases of the Heart, Vol. I. 

By Dujardin-Beaumetz, M. D. 
Diseases of the Heart, Vol. II. 

By Dujardin-Beaumetz, M. D. 
The Modern Treatment of Diarrhoea and 
Dysentery. 

By A. B. Palmer, M. D. 
Intestinal Diseases of Children, Vol. I. 

By A. Jacobi, M. D. 
Intestinal Diseases of Children, Vol. II. 

By A. Jacobi, M. D. 



The Modern Treatment of Headaches. 
By Allan McLane Hamilton, M. D. 

The Modern Treatment of Pleurisy and 
Pneumonia. 

By G. M. Garland, M. D. 

Diseases of the Male Urethra. 

By Fessenden N. Otis, M. D. 
The Disorders of Menstruation. 

By Edward W. Jenks, M. D. 

The Infectious Diseases, Vol. I. 
By Karl Liebermeister. 

The Infectious Diseases, Vol. II- 
By Karl Liebermeister. 



SERIES III. 



Abdominal Surgery. 

By Hal C. Wyman, M. D. 
Diseases of the Liver. 

By Dujardin-Beaumetz, M. D. 
Hysteria and Epilepsy. 

By J. Leonard Corning, M. D. 

Diseases of the Kidney. 

By Dujardin-Beaumetz, M. D. 

The Theory and Practice of the Ophthal- 
moscope. 

By J. Herbert Claiborne, Jr., M. D. 

Modern Treatment of Bright's Disease. 
By Alfred L. Loomis, M. D. 



Clinical Lectures on Certain Diseases of 
the Nervous System! 

By Prof. J. M. Charcot, M. D. 

The Radical Cure of Hernia. 

By Henry O. Marcy, A. M., M. D., 
LL. D. 
Spinal Irritation. 

By William A. Hammond, M. D. 
Dyspepsia. 

By Frank Woodbury, M. D. 
The Treatment of the Morphia Habit. 

By Erlenmeyer. 
The Etiology, Diagnosis and Therapy of 
Tuberculosis. 

By Prof. H. von Ziemssen. 



SERIES IV. 



Nervous Syphilis. 

ByH. C. Wood, M. D. 
Education and Culture as correlated to 
the Health and Diseases of Women. 

By A. J. C. Skene, M. D. 
Diabetes. 

By A. H. Smith, M. D. 
A Treatise on Fractures. 

By Armand Despres, M. D. 
Some Major and Minor Fallacies concern- 
ing Syphilis. 

By E. L. Keyes, M. D. 
Hypodermic Medication. 

By Bournevifle and Bricon. 



Practical Points in the Management of 
Diseases of Children. 

By I. N. Love, M. D. 
Neuralgia. 

By E. P. Hurd, M. D. 
Rheumatism and Gout. 

By F. Le Roy Satterlee, M. D. 
Electricity, Its Application in Med'cine. 

By Wellington Adams, M.D. [Vol.1.} 
Electricity, Its Application in Medicine. 

By Wellington Adams, M.D. [Vol.IL] 
Auscultation and Percussion. 

Ry Frederick C. Shattuck, M. D. 



SERI 

Taking Cold. 

By F. H. Bosworth, M.D. 

Practical Notes on Urinary Analysis. 
By William B. Canfield, M. D. 

Practical Intestinal Surgery. Vol. I. 

By F. B. Robinson, M. D. 
Practical Intestinal Surgery. Vol. II. 

By F. B. Robinson, M. D. 

Lectures on Tumors. 

By John B. Hamilton, M. D., LL. D. 

Pulmonary Consumption, a Nervous Dis- 
ease. 

By Thomas J. Mays, M.D 



ES V. 

Artificial Anaesthetics and Anaesthesia. 
By DeForest Willard, M. D., and Dr. 
Lewis H. Adler, Jr. 

Lessons in the Diagnosis and Treatment 
of Eye Diseases. 

By Casey A. Wood, M. D. 
The Modern Treatment of Hip Disease 

By Charles F. Stillman, M. D. 
Diseases of the Bladder and Prostate. 

By Hal C. Wyman, M. D. 
Cancer. 

By Daniel Lewis, M. D. 
Insomnia and Hypnotics. 

By Germain See. 

[Translated by E. P. Hurd, M. D. 



SERIES VI. 



The Uses of Water in Modern Medicine. 
By Simon Baruch, M. D. Vol. 1 . 

The Uses of Water in Modern Medicine. 
By Simon Baruch, M. D. Vol. II. 

The Electro-Therapeutics of Gynaecol- 
ogy. Vol. I. 
By A. H. Goelet, M. D. 

The Electro-Therapeutics of Gynaecol- 
ogy. Vol. II. 
By A. H. Goelet, M. D. 

Cerebral Meningitis. 

By Martin W. Barr, M. D. 

Contributions of Physicians to English 
and American Literature. 
By Robert C. Kenner, M. D. 



Gonorrhoea and Its Treatment. 
By G. Frank Lydston, M. D. 

Acne and Alopecia. 

By L. Duncan Bulkley, M. D. 

Fissure of the Anus and Fistula in Ano. 
By Dr. Lewis H. Adler, Jr. 

The Surgical Anatomy and Surgery of 
the Ear. 
By Albert H. Tuttle, M. D., S. B. 

Recent Developments in Massage. 
By Douglas Graham, M. D. 

Sexual Weakness and Impotence. 
, By Edward Martin, M. D. 



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Appendicitis and Perityphlitis. 

By Charles Talamon, M. D. 
Cholera. Vol. I. 
Cholera. Vol.il. 

ByG. Archie Stockwell, M.D.,F.Z.S. 
Electro-Therapeutics of Neurasthenia. 

By W. F. Robinson, M. D. 

Diagnosis and Treatment of Surgical 
Affections of the Peripheral Nerves. 

By F. Jenner Hodges, M. D. 
Deformities of the Foot. 

By B. E. McKenzie, M. D. 



Treatment of Steril ty in the Woman. 
By Dr. De Sinety. 

Bacterial Poisons. 

By N. Gamaleia, M. D. 

Treatise on Diphtheria. 

By H. Bourges, M. D. * 
Antiseptic Therapeutics. Vol. I. 
Antiseptic Therapeutics. Vol. ir. 

By E. Trouessart, M. D. 

Treatment of Typhoid Fever. 
By Juhet-Renoy, M. D. 



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THE PRINCIPLES AND PRACTICE OF BANDAGING. .. .$ 3.00 
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SEXUAL IMPOTENCE IN MALE AND FEMALE 3.00 

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